-RC1G 


Ul 


LESSONS 


IN 


PHYSICAL   DIAGNOSIS 


BY 


ALFRED  L.  LOOMIS,  M.D.,  LL.D. 

PROFESSOR  OF  THE  PRACTICE  OF  MEDICINE  AND  PATHOLOGY  IN  THE  UNIVERSITY 
OF  THE  CITY  OF  NEW  YORK 


TENTH  EDITION — REVISED  AND  ENLARGED 


NEW    YORK 
WILLIAM  WOOD  &   COMPANY 

1897 


Entered  according  to  Act  of  Congress,  in  the  year  1593,  by 

WILLIAM  WOOD  &   CO., 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


ALL,  RIGHTS  RESERVED. 


PREFATORY  1TOTE. 


The  tenth  edition  of  this  volume  has  been  thor- 
oughly revised,  and  such  corrections  and  additions  have 
been  made  as  seemed  necessary  to  make  it  a  more  com- 
plete guide  to  the  student  of  Physical  Diagnosis.  The 
section  on  the  "  Physiological  Action  of  the  Heart,"  and 
the  lesson  on  the  "Examination  of  Urine,"  have  been 
entirely  rewritten.  A  new  lesson  on  "  Clinical  Micro- 
scopy "  has  been  added. 

In  the  work  of  revision  and  proof-reading  I  have  re- 
ceived assistance  from  Drs.  Egbert  Le  Fevre  and  War- 
ren Coleman.  The  Author. 

19  West  Thirty-fourth  Street, 
February,  1893. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/lessonsinphysiOOIoom 


CONTENTS. 


LESSON  I. 

PAGE 

Introduction — Topography   of  the    Walls   of   the    Chest — 

Contents  of  the  Various  Regions 3 

LESSON   II. 
Inspection,  Palpation,  and  Mensuration „ . .       11 

LESSON  III. 
Percussion . 19 

LESSON  IV. 
Auscultation  ., 29 

LESSON  V. 

Abnormal  or  Adventitious  Sounds 40 

LESSON  VI. 
Auscultation  of  the  Voice 47 

LESSON  VII. 

A  Synopsis  of  Physical  Signs  in  the  Diagnosis  of  Pulmonary 

Diseases , 53 

LESSON  VIII. 

A  Synopsis  of  Physical  Signs  in  the  Diagnosis  of  Pulmonary 

Diseases — Continued 66 


VI  CONTENTS. 

LESSON   IX. 

PAGE 

Topography  op  the  Heart  and  Aorta— Physiological  Action 

op  the  Heart 81 

LESSON  X. 
Methods  op  Cardiac  Physical  Examination 89 

LESSON  XL 
Abnormal  Sounds  op  the  Heart 97 


LESSON  XII. 

Synopsis  op   the  Physical  Signs    op  Pericarditis — Hypertro- 
phy, Dilatation,  and  Patty  Degeneration  op  Heart.  ....     113 


LESSON  XIII. 

Aneurism  op  the  Thoracic  Aorta  and  Arteria  Innominata — 
Epigastric  Pulsation — Sub-clavian  Murmurs — Venous  Pul- 
sations- and  Murmurs.   121 

LESSON  XIV. 

Abdomen — Introduction— Topography  op  the  Abdomen — Con- 
tents op  the  Various  Regions — Abdominal  Inspection, 
Palpation,  Percussion,  and  Auscultation — Diseased  Con- 
ditions op  the  Peritoneum 131 


LESSON  XV. 

Physical  Signs  op  the   Abnormal  Changes  in  the  Different 

Abdominal  Organs — Stomach — Intestines — Liver — Spleen,     141 

LESSON  XVI. 

Physical  Signs  of  the  Abnormal  Changes  in  the  Different 

Abdominal  Organs — Continued '. 157 


LESSON  XVII. 

Urine— Introduction— Plan  of  Examination— Physical  Char- 
acters —Chemical  Characters— Normal  Elements — Abnor- 
mal Elements 175 


CONTENTS.  Vli 

LESSON   XVIII. 

PAGE 

Clinical  Microscopy — Blood — Sputum — Urine — Vomit — F^ces,     199 

LESSON  XIX. 

Mechanical  Aids  in  the  Diagnosis  op  Diseases  op  the  Respira- 
tory and  Vascular  Organs — Stethoscope — Stethometer — 
Cyrtometer — Cardiometer — Laryngoscope — Sphygmograph    235 

LESSON  XX. 

Mechanical  Aids  in  the  Diagnosis  op  Diseases  of  the  Nervous 
System,  and  in  General  Diseases — Ophthalmoscope — 
Thermometer —  Microscope  —  Dynamometer — ^Esthesiome- 
ter — Exploring  Trocar — Specula 250 


LIST    OF    ILLUSTRATIONS. 


FIG.  PAGE 

1.  The  anterior  region  of  chest,  the  boundaries  of  its  subdivisions, 

and  the  organs  corresponding  to  these  subdivisions,      .        .  5 

2.  The  posterior  region  of  chest,  the  boundaries  of  its  subdivi- 

sions, and  the  organs  corresponding  to  these  subdivisions,  8 

3.  Diagram  illustrating  the  production  of  rales,     ....  41 

4.  Cavernous  respiration  and  gurgles 44 

5.  Roughening  of  the  pleurae,  and  slight  pleuritic  effusion,          .  45 

6.  Diagram  illustrative  of  the  physical  signs  of  the  three  stages  of 

pneumonia 58 

7.  Diagram  showing  the  pleural  cavity  completely  filled  with 

liquid,  the  lung  being  compressed, 68 

8.  Diagram  illustrative  of  the  physical  signs  of  hydro-pneumo- 

thorax, 73 

9.  Diagram  showing  the  changes  in  the  valves  and  cavities  of  one 

side  of  the  heart  during  a  cardiac  pulsation,  ...  84 

10.  Representation  of  the  movements  and  sounds  of  the  heart  dur- 

ing a  cardiac  cycle, 86 

11.  Representation  of  the  altered  relations  of  the  sounds  in  slowed 

or  accelerated  heart  action, 87 

12.  Diagram  illustrating  the  mode  of  production  of  cardiac  mur- 

murs in  the  left  heart,  and  the  condition  of  the  valves  and 
cavities  during  their  production,  100 

13.  Diagram  showing  the  areas  of  cardiac  murmurs,       .         .        .         104 

14.  Diagram  showing  the  pericardial  sac  partially  filled  with  liquid, 

and  plastic  exudation  upon  the  two  surfaces  of  the  pericar- 
dium above  the  level  of  the  liquid, 114 

15.  Hypertrophy  of  left  ventricle,  116 

16.  Hypertrophy  of  right  ventricle,  .        .        .         .         .        .         117 

17.  Diagram  showing  the  different  regions  of  the  abdomen,  and 

the  organs  contained  in  each,  which  are  visible  on  the  re- 
moval of  the  abdominal  walls, 133 

18.  The  volume  of  the  liver  "in  various  diseases,       ....         146 

19.  Diagram  representing  the  different  areas    occupied  by  the 

spleen  in  its  various  enlargements  into  the  abdominal  cavity,        154 

20.  Diagram  showing  the  gradual  enlargement  of  a  tumor  of  the 

right  ovary  till  it  fills  a  large  portion  of  the  abdominal  cav- 
ity,   165 


LIST   OF   ILLUSTRATIONS. 


FIG. 

21. 

Urinometer, 

22. 

Ureometer, 

23. 

Albuminometer,          .... 

24. 

Saccharometer,            .... 

25. 

Cellular  elements  of  human  blood,    . 

26. 

Blood  from  case  of  leucocythaemia,    . 

27. 

Poikilo-,  macro-,  and  microcytes, 

28. 

Spirillum  of  relapsing  fever, 

29. 

Bacillus  of  anthrax, 

30. 

Bacillus  of  typhoid  fever, 

81. 

Plasmodium  malarise, 

32. 

Filaria  sanguinis  hominis, 

33. 

Curschmann's  spirals, 

34. 

Bronchial  cast, 

35. 

Elastic  tissue, 

36. 

Tubercle  bacilli  from  sputum,  . 

37. 

Actinomyces,  or  ray  fungus, 

38. 

Pneumococcus,            .... 

39. 

Echinococcus  hooklets, 

40. 

Urate  of  soda, 

41. 

Urate  of  soda  with  spicula,         .         . 

42. 

Urate  of  ammonia,      .... 

43. 

Uric  acid, 

44. 

Calcium  oxalate,         .... 

45  and  46.     Ammonio-magnesium,  or  "triple ' 

47. 

Calcium  phosphate,    .... 

48. 

Cystin,         .*.... 

49. 

Leucin, 

50. 

Tyrosin,      .... 

51. 

Pus  corpuscles,           .... 

52. 

Pus  corpuscles  treated  with  acetic  acid, 

53. 

Epithelial  cells,           .... 

54. 

Spermatozoa, 

55. 

Types  of  hyaline  casts,       .         . 

56. 

Epithelial  casts,          .... 

57. 

Granular  casts,            .... 

58. 

Fatty  casts, 

59. 

Blood  casts, 

60. 

Torula  cerevisise,        .... 

61. 

Penicilium  glaucum,           .         .         . 

62. 

Sarcinae, 

63. 

Gonococci, 

64. 

Hsemin  crystals,         .... 

65. 

Cholera  bacilli  from  faeces, 

66. 

Amoebae  coli, 

67. 

Eggs  of  intestinal  ova, 

68. 

Stethoscope 

S9. 

Stethometer, 

phosphates, 


PAGE 

180 
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188 
192 
200 
201 
203 
204 
205 
205 
206 
206 
208 
20  S 
209 
213 
214 
214 
215 
216 
216 
216 
217 
218' 
218 
219 
219 
220 
220 
221 
221 
222 
223 
223 
224 
224 
225 
225 
226 
226 
226 
227 
228 
230 
231 
232 
235 
236 


LIST   OF   ILLUSTRATIONS. 


XI 


FIG. 

70.  Cyrtometer,         .         .    .    . 

71.  Cardiometer,       ....... 

72.  Laryngeal  mirror,  . 

73.  Head  mirror,       ....... 

74.  Nasal  speculum,         ..        =        =,. 

75.  Marey's  sphygmograph,     .... 

76.  Normal  pulse  tracing,         .... 

77.  A  dicrotic  pulse  tracing, 

78.  Pulse  tracing  in  aortic  regurgitation, 

79.  Pulse  tracing  in  aortic  stenosis, 

80.  Pulse  tracing  from  a  case  of  atheroma, 

81.  Tracing  from  frequent  pulse,     . 

82.  Pulse  tracing  in  mitral  obstruction,   . 

83.  Pulse  tracing  in  aneurism  of  ascending  aorta, 

84.  Liebreich's  ophthalmoscope, 

85.  Straight  self-registering  thermometer, 

86.  Microscope, 

87.  Dynamometer,    ...... 

88.  ^Ethesiometer,    ...... 

89  Dieulafoy's  exhausting  syringe, 


PAGE 

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239 
239 

240 
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245 
247 
247 
24s 
248 
248 
249 
249 
249 
251 
2i7 
262 
263 
264 
266 


LUNGS. 


LESSOR  I. 

INTRODUCTION — TOPOGRAPHY     OF      THE     WALLS      OF      THE 
CHEST — CONTENTS   OF   THE  VARIOUS   REGIONS. 

Gentlemen . 

Physical  Diagnosis  is  a  term  used  to  designate  those 
methods  which  are  employed  for  detecting  disease  dur- 
ing life  by  the  anatomical  changes  which  it  has  produced. 
The  nature  and  extent  of  such  changes  can  be  recognized 
and  appreciated  by  the  deviations  which  they  cause  in 
the  affected  organs  from  the  known  physical  condition 
of  these  organs  when  in  health.  The  significance  of 
physical  signs  in  disease  can  be  determined,  not  by  the- 
ory, but  only  through  clinical  observation  confirmed  by 
examinations  after  death. 

There  are  five  methods  of  eliciting  these  physical  signs, 
termed  "physical  methods  of  diagnosis,"  viz.,  Inspec- 
tion, Palpation,  Mensuration,  Percussion,  and  Ausculta- 
tion. 

The  most  important  of  these  are  Auscultation  and  Per- 
cussion. The  other  methods  are  only  subsidiary  to  these 
two,  and  can  seldom  be  regarded  as  furnishing  positive 
evidence  of  disease.  For  a  complete  and  accurate  physi- 
cal exploration  you  must  sometimes  employ  all  these 
different  methods,  and  with  all,  therefore,  you  should 
become  familiar. 

In  order  to  localize  physical  signs,  the  chest  has  been 
divided  into  artificial  regions  ;  but  as  the  limits  of  these 


4  PHYSICAL   DIAGNOSIS. 

regions  are  arbitrary,  the  boundaries  adopted  by  different 
writers  vary.  The  following  divisions,  which  correspond 
very  nearly  to  those  proposed  by  many  authorities, 
you  will  find,  I  think,  sufficiently  small  and  well  de- 
fined for  practical  purposes.  It  is  important  that  you 
should  be  f  amiliar,  not  only  with  the  boundaries  of  these 
regions,  but  with  the  relative  position  of  the  structures 
and  organs  or  portions  of  organs  included  within  them. 

The  surface  of  the  chest  may  be  divided  into  three 
general  regions — Anterior,  Posterior,  and  Lateral.  The 
Anterior  region,  on  either  side,  may  be  subdivided  into 
Supra- Clavicular,  Clavicular,  Infra- Clavicular,  Mam- 
mary, and  Infra-Mammary.  Between  the  two  anterior 
regions  we  have  the  Supra- Sternal,  Superior  Sternal, 
and  the  Inferior  Sternal.  The  Posterior  region,  on 
either  side,  may  be  subdivided  into  the  Supra- Scapular, 
Scapular,  and  Infra- Scapular.  Between  these  you 
have  the  Inter- Scapular.  The  Lateral  region,  on  either 
side,  may  be  subdivided  into  Axillary  and  Infra-Axil- 
lary regions. 

The  Supra- Clavicular  region  is  a  triangle  whose 
base  corresponds  to  the  trachea  ;  whose  lower  side,  to  the 
upper  border  of  the  clavicle  ;  and  whose  upper  side,  to  a 
line  drawn  from  the  outer  third  of  the  clavicle  to  the 
upper  rings  of  the  trachea.  This  region  contains,  on 
either  side,  the  apex  of  the  lung,  with  portions  of  the 
subclavian  and  carotid  arteries,  and  the  subclavian  and 
jugular  veins. 

The  Clavicular  space  is  that  which  lies  behind  the 
inner  three-fifths  of  the  clavicle,  and  has  the  bone  for  its 
boundary.  It  is  occupied  on  both  sides  by  lung  tissue; 
on  the  right  side,  at  its  outer  extremity,  lies  the  subcla- 
vian artery ;  at  the  sterno-clavicular  articulation,  the 
arteria  innominata.     On  the  left  side,  almost   at  right 


INFRA-CLAVICULAR   REGION.  5 

angles  with  the  bone,  and  deeply  seated,  are  the  carotid 
and  subclavian  arteries. 

The  Infra-Clavicular  region  has  for  its  boundaries 
the  clavicle  above,  the  lower  border  of  the  third  rib  be- 
low, the  edge  of  the  sternum  inside,  and  outside  a  line 
falling  vertically  from  the  junction  of  the  middle  and 


Fig.  1.— The  Anterior  Eegion,  the  Boundaries  of  its  Subdivisions,  and  the  Organs  cor- 
responding to  these  Subdivisions. 


outer  thirds  of  the  clavicle.  Within  these  limits,  on 
both  sides,  you  will  find  the  superior  lobe  of  the  lung 
and  the  main  bronchi;  the  right  bronchus  lies  behind, 
and  the  left  a  little  below  the  second  costal  cartilage. 
On  the  right  side,  close  to  the  sternal  border  of  the  re- 
gion, lie  the  superior  cava  and  a  portion  of  the  arch  of 


6  PHYSICAL  DIAGNOSIS. 

the  aorta;  on  the  left,  a  portion  of  the  pulmonary  artery. 
The  aorta  and  pulmonary  artery  are  immediately  behind 
the  second  sterno-costal  articulations;  the  one  on  the 
right,  the  other  on  the  left  side  of  the  sternum.  On  the 
left  side  the  lower  boundary  of  the  region  very  nearly 
corresponds  to  the  base  of  the  heart. 

The  Mammary  region  is  bounded  above  by  the  third 
rib;  below,  by  the  inferior  margin  of  the  sixth  rib;  in- 
side, by  the  edge  of  the  sternum  ;  and  outside,  by  a  verti- 
cal line,  continuous  with  the  outer  border  of  the  infra- 
clavicular region.  You  will  find  this  region  to  differ 
materially  in  its  contents  on  the  two  sides.  On  the 
right  side  the  lung  is  found  extending,  in  front,  down  to 
the  sixth  rib,  where  its  thin,  sharp  border  very  nearly 
corresponds  to  the  lower  boundary  of  the  region.  The 
right  wing  of  the  diaphragm,  though  not  attached  higher 
than  the  seventh  rib,  is  usually  pushed  up  by  the  liver 
as  high  as  the  fourth  interspace;  a  portion  of  the  right 
auricle  of  the  heart,  and  the  superior  angle  of  the  right 
ventricle,  lie  close  to  the  sternum,  between  the  third  and 
fifth  ribs.  On  the  left  side  the  lung  is  in  front  as  far  as 
the  fourth  sterno-costal  articulation,  where  its  anterior 
border  passes  outward  until  it  reaches  the  fifth  rib 
(leaving  an  open  space  for  the  heart);  then  it  crosses 
forward  and  downward  as  far  as  the  sixth  rib  ;  a  small 
portion  of  the  apex  of  the  right  ventricle  is  also  found 
within  this  region. 

The  Infra-Mammary  region  is  bounded  above  by  the 
lower  border  of  the  sixth  rib;  below,  by  a  curved  line 
corresponding  to  the  edges  of  the  false  ribs;  inside,  by 
the  inferior  portion  of  the  sternum  ;  and  outside,  by  the 
continuation  of  the  outer  boundary  of  the  mammary  re- 
gion. This  region,  on  the  right  side,  contains  the  liver, 
with  a  portion  of  the  lung  in  front,  on  a  full  inspiration. 


LOWER    STERNAL   REGION.  7 

On  the  left,  lying  in  front,  near  the  median  line,  you 
have  a  portion  of  the  left  lobe  of  the  liver,  the  stomach, 
and  the  anterior  border  of  the  spleen.  The  stomach  and 
spleen  usually  rise  to  a  level  with  the  sixth  rib. 

The  Supra-Sternal  region  is  the  space  which  lies  im- 
mediately above  the  notch  of  the  sternum,  and  is 
bounded  on  either  side  by  the  sterno-mastoid  muscle. 
It  is  occupied  chiefly  by  the  trachea,  by  the  arteria  in  no- 
minata  at  its  lower  right  angle,  and  by  the  arch  of  the 
aorta,  which  sometimes  reaches  to  its  lower  border, 
where,  on  firm  downward  pressure  with  the  end  of  the 
finger,  you  will  often  be  able  to  feel  it. 

The  Upper  Sternal  region  is  the  space  bounded  by 
that  portion  of  the  sternum  which  lies  above  the  lower 
margin  of  the  third  rib.  In  this  region  the  lungs  he  in 
front,  but  do  not  completely  close  in  the  space.  Imme- 
diately behind  them  are  the  ascending  and  transverse 
portions  of  the  aorta,  and  the  pulmonary  artery  from  its 
origin  to  its  bifurcation.  The  left  vena  innominata  crosses 
the  sternum  a  little  below  its  upper  border.  Situated 
deeply,  at  the  junction  of  the  first  and  second  bones  of 
the  sternum,  is  the  trachea,  dividing  into  its  two  bron- 
chi. The  pulmonary  valves  are  situated  behind  the  left 
edge  of  the  sternum,  at  its  junction  with  the  third  costal 
cartilage.  The  aortic  valves  are  about  half  an  inch  lower 
down,  and  midway  between  the  median  line  and  the 
left  edge  of  the  sternum. 

The  Lower  Sternal  region  corresponds  to  that  por- 
tion of  the  sternum  which  lies  below  the  lower  margin 
of  the  third  rib.  Throughout  the  whole  extent  of  this 
region,  on  the  right  side,  the  lung  is  in  front:  it  also  ex- 
tends down  on  the  left  side  as  far  as  the  fourth  sterno- 
costal articulation:  below  this  lies  the  greater  part  of  the 
right  ventricle,   and  a  small  portion  of  the  left.     The 


PHYSICAL  DIAGNOSIS. 


Fig.  2.— The  Posterior  Region,  the  Bound  iries  of  its  Subdivisions,  and  the  Organs  cor- 
responding to  thess  Subdivisions.     (Aftar  Sibsok.) 


INTER- SCAPULAR  REGION.  9 

mitral  valve,  deepest  of  all,  is  situated  behind  the  third 
left  intercostal  space,  about  one  inch  from  the  sternum; 
the  tricuspid  valve  is  near  the  middle  of  the  sternum, 
at  the  level  of  the  fourth  costal  cartilage.  Inferiorly  is 
the  attachment  of  the  heart  to  the  diaphragm;  below 
this  is  a  small  portion  of  the  liver,  and  sometimes  of  the 
stomach. 

The  Supra-Scapular  and  Scapular  regions  together 
occupy  the  space  from  the  second  to  the  seventh  rib,  and 
are  identical  in  their  outlines  with  the  upper  and  lower 
fossae  of  the  scapula.  These  regions  are  occupied  by 
lung  substance. 

The  Infra-Scapular  region  is  bounded  above  by  the 
inferior  angle  of  the  scapula  and  the  seventh  dorsal  ver- 
tebra; below,  by  the  twelfth  rib;  outside,  by  the  poste- 
rior border  of  the  lower  axillary  region  ;  and  inside,  by 
the  spinous  processes  of  the  vertebrae.  Immediately  un- 
derneath the  surface,  as  far  as  the  eleventh  rib,  this  re- 
gion is  occupied  by  the  lungs.  On  the  right  side  the 
liver  extends  downward  beyond  the  level  of  the  eleventh 
rib;  on  the  left  the  intestine  occupies  the  inner  part  of 
this  region,  and  the  spleen  the  outer.  Close  to  the  spine, 
on  each  side — more  on  the  left  than  on  the  right — a 
small  portion  of  the  kidney  is  found;  along  the  left  side 
of  the  spine  runs  tbe  descending  aorta. 

The  Inter-Scapular  region  is  the  space  between  the 
inner  margin  of  the  scapula  and  the  spines  of  the  dorsal 
vertebrae,  from  the  second  to  the  sixth.  This  region 
contains,  on  both  sides,  lung  substance,  the  main  bron- 
chi, and  the  bronchial  glands.  It  also  encloses  on  the 
left  side  the  oesophagus,  and  from  the  upper  part  of  the 
fourth  dorsal  vertebra  downward,  the  descending  aorta. 
The  bifurcation  of  the  trachea  will  be  found  opposite  the 
third  dorsal  vertebra. 


10  PHYSICAL   DIAGNOSIS. 

The  Axillary  region  has  for  its  limits  the  axilla, 
above  ;  below,  a  line  carried  backward  from  the  lower 
boundary  of  the  mammary  region  to  the  inferior  angle 
of  the  scapula;  in  front,  the  outer  margin  of  the  infra- 
clavicular and  mammary  regions;  and  behind,  the  exter- 
nal edge  of  the  scapula.  This  region  corresponds  to  the 
upper  lobes  of  the  lungs,  with  the  main  bronchi  deeply 
seated. 

The  Infra- Axillary  region  is  bounded  above  by  the 
axillary  region;  anteriorly,  by  the  infra-mammary;  pos- 
teriorly, by  the  infra- scapular;  and  below,  by  the  edges 
of  the  false  ribs.  This  region  contains,  on  both  sides, 
the  lower  edge  of  the  lung  sloping  downward  and  back- 
ward. On  the  right  side  is  the  liver,  and  on  the  left 
the  stomach  and  spleen. 


LESS01ST  II. 

INSPECTION,    PALPATION,    AND   MENSURATION. 

Inspection  is  the  ocular  examination  of  the  external 
surface.  Though  usually  secondary  in  importance  to 
Auscultation  and  Percussion,  it  should  not  be  lightly  re- 
garded, for  it  often  furnishes  you  much  information  re- 
specting the  condition  of  the  thoracic  and  abdominal 
viscera.  By  Inspection  you  recognize  changes  in  the 
size,  form,  or  symmetry  of  the  cavities  in  which  they 
are  contained,  and  in  the  movements  of  their  walls  dur- 
ing respiration,  as  regards  their  rhythm,  frequency,  or 
force. 

As  students  of  anatomy  you  are  familiar  with  the 
form  of  a  well-proportioned  chest ;  a  description  of  it  is, 
therefore,  unnecessary.  Suffice  it  to  say  that,  in  a  nor- 
mal state,  the  two  sides  are  symmetrical  in  every  part ; 
the  intercostal  spaces  are  more  or  less  distinct,  accord- 
ing as  the  individual  is  more  or  less  fat.  Normal  breath- 
ing is  of  two  kinds,  costal  and  diaphragmatic.  In  the 
costal  the  movements  are  chiefly  thoracic ;  in  the  dia- 
phragmatic they  are  chiefly  abdominal.  In  quiet  respi- 
ration you  will  notice  the  abdominal  wall  rise  with  in- 
spiration, and  fall  with  expiration  ;  at  the  same  time 
you  will  observe  a  lateral  expansion  of  the  lower  ribs, 
and  a  slight  upward  movement  of  the  upper  part  of  the 
chest  with  inspiration,  and  a  downward  movement  with 
expiration.  The  movements  of  respiration  in  these 
three    situations    are    called,    respectively,    abdominal, 


12  PHYSICAL    DIAGNOSIS. 

inferior  costal,  and  superior  costal.  In  the  female,  the 
costal  breathing  is  most  marked ;  in  the  male,  the  dia- 
phragmatic. The  number  of  respirations  to  the  minute 
varies  at  different  periods  of  life  ;  in  childhood  it  is 
about  twenty-six ;  from  the  twentieth  year,  about  six- 
teen to  twenty. 

Considerable  alterations  in  the  form  and  movements 
of  the  chest  are  compatible  with  a  healthy  condition  of 
the  thoracic  viscera.  You  rarely  meet  with  a  perfectly 
symmetrical  chest,  even  among  the  healthy.  In  my  ex- 
amination of  fifteen  hundred  persons  I  found  only  one 
well-proportioned,  symmetrical  chest  in  seven.  As  you 
can  easily  recognize  these  healthy  deviations  from  sym- 
metry, I  shall  not  enter  into  details  concerning  them.  I 
would,  however,  mention  that  slight  curvatures  of  the 
spine,  either  acquired  or  the  result  of  former  disease  of 
the  vertebrae,  cause  the  majority  of  these  deviations. 

We  will  first  consider  only  those  changes  in  the  size, 
form,  and  movements  of  the  thoracic  cavity  which  are 
the  result  of  disease  of  the  thoracic  organs;  confining 
ourselves,  at  present,  to  the  lungs  and  pleurae.  The 
readiest  way  of  presenting  these  changes  to  you,  it 
seems  to  me,  is  to  consider  them  as  they  occur  in  the 
different  thoracic  affections.  First  we  will  consider  the 
signs  obtained  by  inspection  in  pleurisy.  In  the  first 
stage,  prior  to  the  occurrence  of  much  liquid  effusion, 
there  is  no  apparent  change  in  the  size,  but  the  move- 
ments of  the  affected  side  are  diminished,  and  those  of 
the  healthy  are  increased  ;  you  have  what  is  termed  a 
catching  respiration.  This  sign  is  not  distinctive  of 
pleurisy ;  it  is  present  in  intercostal  neuralgia  and  in 
pleurodynia.  In  the  stage  of  liquid  effusion,  if  the  liquid 
is  sufficient  to  compress  the  lung  and  dilate  the  thoracic 
walls,  the  affected  side  will  be  increased  in  size,  and,  in 


INSPECTION.  13 

proportion  to  the  dilatation,  its  movements  are  restricted 
or  arrested.  If  the  cavity  is  completely  filled  with  liquid, 
there  will  be  bulging  and  widening  of  the  intercostal 
spaces,  with  more  or  less  displacement  of  the  adjacent 
viscera.  As  the  liquid  is  absorbed  the  lung  expands,  but 
not  to  the  same  volume  it  had  before.  It  remains  more 
or  less  contracted,  and  the  consequence  is,  retraction  of 
the  affected  side  from  atmospheric  pressure.  Generally, 
if  the  liquid  effusion  shall  have  existed  a  considerable 
length  of  time  previous  to  absorption,  the  subsequent  re- 
traction is  marked,  and  you  can  determine  at  once  by 
inspection  that  pleurisy  has  existed  at  some  period  more 
or  less  remote. 

In  pulmonary  emphysema,  if  it  is  a  well-marked 
case,  on  inspection  you  will  notice  a  dilatation  of  the 
upper  portion  of  the  chest,  while  its  whole  aspect  ap- 
pears more  rounded  than  in  health,  so  that  it  has  re- 
ceived the  name  "  barrel-shaped  "  chest ;  the  shoulders 
are  elevated  and  brought  forward ;  the  movements  in 
respiration  are  limited  to  the  lower  portions  of  the  chest 
and  to  the  abdomen.  On  inspiration  there  is  no  out- 
ward expansive  movement  of  the  ribs  ;  the  sternum 
and  ribs  seem  to  move  up  and  down  as  if  they  were 
composed  of  one  solid  piece;  in  some  cases  of  long  stand- 
ing you  will  have  actual  falling-in  instead  of  expansion 
of  lower  ribs  during  inspiration.  In  a  well-marked 
case  of  emphysema,  inspection  is  quite  sufficient  for  a 
diagnosis  ;  but  where  the  lungs  are  but  slightly  emphy- 
sematous, inspection  furnishes  no  positive  information. 
In  pneumonia,  the  only  sign  furnished  by  inspection  is 
that  the  movements  of  the  affected  side  are  restrained,  as 
in  the  first  stage  of  pleurisy.  In  pulmonary  tuberculosis 
inspection  furnishes  you  important  information.  De- 
pression in  the  infra-clavicular  region  on  the  affected 


14  PHYSICAL   DIAGNOSIS. 

side  is  an  early  sign  of  tubercular  deposit.  In  advanced 
tuberculosis,  the  depression  is  still  more  marked,  in  some 
instances  amounting  almost  to  deformity.  The  expan- 
sive movements  in  inspiration  on  the  affected  side,  in 
the  infra-clavicular  region,  are  diminished  or  entirely 
wanting,  and  this  want  of  expansion  is  often  noticeable 
at  a  very  early  period  in  the  disease. 

Bulging  or  partial  enlargement  of  the  chest,  deter- 
minable by  inspection,  occurs  in  various  affections.  En- 
largement of  the  prsecordia  is  observed  in  certain  cases 
of  hypertrophy  or  dilatation  of  the  heart,  or  from  liquid 
effusion  in  the  pericardium.  Bulging  occurs  also  over 
aneurismal  and  other  tumors 

In  cases  of  membranous  croup,  acute  and  chronic 
laryngitis,  and  cedema  glottidis,  inspection  will  disclose 
to  you  the  seat  of  the  obstruction  to  the  passage  of  air 
to  the  lung  by  a  sinking-in  during  inspiration  of  the 
parts  of  the  chest  which  yield  most  readily  to  atmo- 
spheric pressure.  This  sinking-in  on  inspiration  you 
will  notice  first  in  the  supra-clavicular  spaces,  then  in  the 
infra-clavicular  spaces,  and,  as  the  obstruction  increases, 
the  sternum  is  depressed  and  the  sides  contracted. 

Although  furnishing  few  positive  evidences  of  disease, 
you  should  always  employ  inspection  prior  to  the  other 
methods  of  physical  exploration.  This  is  important  in 
all  cases  where  the  evidences  furnished  by  the  other 
physical  signs  are  not  conclusive. 

Palpation,  or  the  act  of  laying  on  the  hand  and  feel- 
ing the  external  surface  of  the  body,  is  less  useful  than 
inspection  in  ascertaining  deformities,  and  the  amount 
of  general  movement ;  but  it  is  more  useful  in  deter- 
mining the  amount  of  local  expansion,  and  the  charac- 
ter of  vibration  or  impulses  communicated  to  the  exter- 
nal surface. 


PALPATION.  15 

In  order  to  arrive  at  satisfactory  results  from  its  em- 
ployment, you  should  observe  the  precautions  already 
named  as  influencing  accurate  inspection  ;  beyond  this, 
I  need  only  mention  that  in  thoracic  examinations  the 
hand  or  the  fingers  should  be  gently  and  evenly  applied 
to  the  surface  of  the  chest,  and  that  corresponding  por- 
tions of  the  two  sides  of  the  thorax  should  be  examined 
simultaneously,  the  one  with  the  right  hand  and  the 
other  with  the  left.  If  you  lay  your  hand  lightly  upon 
the  surface  of  the  chest  of  a  healthy  person  while  speak- 
ing, a  delicate  tremulous  vibration  will  be  felt,  varying 
in  intensity  with  the  loudness  and  coarseness  of  the 
voice  and  the  lowness  of  its  pitch  ;  this  is  called  normal 
vocal  fremitus.  As  a  rule,  vocal  fremitus  fe  more 
marked  in  adults  than  in  children,  in  males  than  in  fe- 
males, and  in  thin  than  in  fat  persons.  In  the  right  in- 
fra-clavicular region  it  is  more  marked  than  in  the  left. 
Variations  in  the  vocal  fremitus  are  the  most  important 
evidences  of  disease  furnished  by  palpation  ;  in  fact,  all 
other  evidences  of  pulmonary  disease  afforded  by  palpa- 
tion are  better  obtained  by  inspection. 

In  disease,  the  normal  vocal  fremitus  may  be  in- 
creased, diminished,  or  entirely  absent. 

Increased  vocal  fremitus  occurs  in  those  affections  in 
which  lung  tissue  becomes  more  or  less  solidified,  as 
in  tuberculosis,  pneumonia,  pulmonary  apoplexy,  and 
oedema  of  the  lung.  When  the  consolidation  is  ex- 
treme, involving  bronchial  tubes  of  considerable  size, 
the  vocal  fremitus  may  be  diminished  or  even  absent ; 
while  increase  in  the  size  of  the  bronchial  tubes,  with 
the  slight  adjacent  consolidation  met  with  in  chronic 
bronchitis,  often  gives  rise  to  increased  vocal  fremitus. 

Diminution  or  absence  of  the  normal  vocal  fremitus 
occurs  whenever  the  lung  substance  is  separated  from 


16  PHYSICAL  DIAGNOSIS. 

the  chest  walls  by  gaseous  or  liquid  accumulations  in 
the  pleural  cavity,  as  in  pneumothorax,  serous,  plastic, 
hemorrhagic,  or  purulent  pleuritic  effusions.  In  vesi- 
cular emphysema,  owing  to  the  dilated  condition  of  the 
air  cells,  vocal  fremitus  is  diminished.  Besides  these 
valuable  indications  furnished  by  vocal  fremitus,  you 
may  employ  palpation  to  detect  the  friction  caused  in 
pleurisy  by  the  rubbing  together  of  the  two  roughened 
surfaces  of  the  pleural  membrane,  and  which  is  termed 
friction  fremitus. 

Sibilant  and  sonorous  rales  also  sometimes  throw  the 
bronchial  tubes  into  vibration,  sufficiently  strong  to  be 
felt  on  the  surface  of  the  chest  ;  this  is  termed  sonorous 
or  rhonchial  fremitus.  Cavernous  gurgles  produced  in 
excavations  near  the  surface  may  be  accompanied  with 
a  marked  fremitus. 

Palpation  may  also  be  employed  to  detect  points  of 
tenderness,  and  to  determine  the  density  and  condition 
of  tumors. 

Mensuration  is  another  method  of  physical  explora- 
tion, employed  for  obtaining  information  similar  to  that 
furnished  by  inspection  and  palpation.  We  seldom  em- 
ploy it  in  physical  examinations  of  the  lungs  unless 
great  accuracy  is  required,  as  in  the  record  of  cases. 
The  instruments  which  have  been  devised  for  the  mea- 
surement of  the  chest,  and  the  different  lines  of  measure- 
ment, are  numerous.  The  circular  measurement  is  the 
only  one  that  I  have  found  of  practical  value  in  investi- 
gating pulmonary  disease.  The  simplest  and  most  ac- 
curate mode  of  measuring  the  circular  dimensions  of  the 
chest  is  by  means  of  the  instrument  devised  by  Dr. 
Hare,  which  consists  of  two  pieces  of  tape  similarly  grad- 
uated, joined  together,  and  padded  on  their  inner  sur- 
face  close  to   the  line   of    junction  ;    the    saddle   thus 


MENSURATION.  17 

formed,  when  placed  over  the  spine,  readily  adjusts  it- 
self to  the  spinous  processes,  and  becomes  fixed  suffi- 
ciently for  the  purpose  of  mensuration.  For  comparing 
the  expansive  movements  of  the  two  sides  you  will  find 
Dr.  Quain's  stethometer '  very  useful.  The  object  of  the 
circular  measurement  of  the  chest  is  twofold — first,  to 
ascertain  the  comparative  bulk  of  the  two  sides  ;  second, 
to  ascertain  the  amount  of  expansion  and  retraction  ac- 
companying inspiration  and  expiration  of  the  two  sides. 
The  points  of  measurement  are  the  spinous  processes  be- 
hind and  the  median  line  in  front,  on  the  level  of  the 
sixth  costo-sternal  articulation. 

The  average  circular  dimension  of  the  chest  at  this 
point  in  fifteen  hundred  healthy  persons  was  thirty-two 
and  a  half  inches.  I  also  found  in  these  examinations 
that  about  four-fifths  of  healthy  adults  have  irregularity 
of  the  two  sides.  In  right-handed  individuals  the  right 
side  is  about  one-half  inch  larger  than  the  left ;  in  left- 
handed,  the  left.     This  is  true  of  both  sexes. 

The  really  important  point  of  mensuration  in  pulmon- 
ary diseases  is  the  comparison  of  the  two  sides  of  the 
chest,  in  rest  and  in  motion.  When  a  pleural  cavity  is 
distended  with  air  or  fluid,  the  measurement  of  the  af- 
fected side  may  exceed  that  of  the  healthy  side  by  two 
or  three  inches  ;  after  the  removal  of  the  fluid  there 
may  be  an  equal  diminution  in  the  measurement  of  the 
affected  side,  as  compared  with  the  healthy  one. 

Deficiency  of  expansion  is  also  very  marked  in  certain 
diseases.  In  empyema,  for  instance,  you  will  often  find 
the  total  difference  between  the  fullest  inspiration  and 
the  fullest  expiration,  on  the  affected  side,  will  scarcely 
exceed  one-sixteenth  of  an  inch,  while  on  the  other  side 
there  may  be  a  difference  of  two  or  three  inches. 

1  See  page  236. 

2 


18  PHYSICAL   DIAGNOSIS. 

The  list  of  affections  in  which  variations  in  expansion 
are  to  be  estimated  by  measure  are  the  same  as  those  re- 
ferred to  under  the  head  of  Inspection. 

The  measurement  of  the  capacity  of  the  lungs  for  air, 
by  means  of  Dr.  Hutchinson's  spirometer,  or  of  the 
"  vital  capacity  of  the  chest, "  as  he  terms  it,  has  been 
shown  by  experience  to  be  very  unreliable,  and  his  in- 
strument has  fallen  almost  entirely  into  disuse. 


LESSOR  III. 

PERCUSSION. 

Percussion,  as  a  means  of  diagnosis,  is  not  of  recent 
date,  for  we  find  it  mentioned  by  Hippocrates.  But  as 
the  only  mode  of  practising  it  was  by  striking  the  surface 
itself  with  the  tips  of  the  fingers,  or  knuckles,  now 
termed,  technically,  immediate  percussion,  its  uses  were 
very  limited.  Within  our  time,  however,  M.  Piorry  gave 
it  an  entirely  new  value  by  introducing  mediate  percus- 
sion— the  stroke  being  made,  not  on  the  surface,  but  on 
some  intervening  substance  applied  to  it ;  and  he  so 
demonstrated,  by  experiments  on  living  and  dead  bodies, 
its  superior  applicability  for  determining  changes  in  the 
subjacent  parts,  that  mediate  percussion  ranks  now  only 
second  to  auscultation  among  the  methods  of  physical 
exploration. 

To  estimate  the  value  of  percussion  and  to  understand 
its  true  significance,  you  must  first  learn  to  appreciate 
correctly  the  elements  of  sound.  Authors  have  employed 
a  variety  of  terms  to  designate  them,  such  as  clearness, 
dulness,  emptiness,  fulness,  etc.;  but  I  think  that  a 
classification  based  upon  analysis  of  the  elements  of 
sound  in  general,  will  afford  us  the  truest  and  most  prac- 
tical distinctions,  especially  in  estimating  the  sounds  in 
thoracic  percussion.  Those  elements  or  acoustic  proper- 
ties of  percussion  sounds  which  concern  us  clinically  are 
termed,  respectively,  Intensity,  Pitch,  Quality,  and  Du- 
ration. 


20  PHYSICAL  DIAGNOSIS. 

The  Intensity  of  a  percussion  sound  may  be  increased 
or  diminished  by  increasing  or  diminishing  the  force  of 
the  percussion  blow.  But  in  pulmonary  percussion,  you 
"will  find  that  the  intensity  depends  not  only  on  the  force 
of  the  blow,  but  is  further  modified  by  the  amount  of  air 
contained  in  the  lung  tissue,  by  the  thickness  of  the  soft 
parts  covering  the  thoracic  walls,  and  also  by  the  elas- 
ticity of  the  costal  cartilages. 

The  Pitch  of  the  percussion  sound  is  always  low  over 
healthy  lung  substance,  and,  as  a  rule,  the  greater  the 
quantity  of  air  contained  in  the  corresponding  pulmonary 
tissue,  the  lower  the  pitch  ;  consequently,  you  will  find 
the  pitch  of  the  percussion  sound  varying  very  percept- 
ibly in  the  different  regions  of  a  healthy  chest.  You 
can,  however,  familiarize  the  ear  with  the  characters  of 
normal  pitch  only  by  constant  practice. 

Quality  in  sound  is  that  element  by  which  we  distin- 
guish any  given  sound  from  every  other.  Thus  it  is  by 
the  quality  that  you  know  the  sound  of  one  musical  in- 
strument from  another.  The  quality  of  the  note  emitted 
on  percussion  over  healthy  lung  substance,  and  termed 
normal  vesicular  resonance,  is  sufficiently  marked  and 
peculiar  to  be  easily  recognized,  though  it  cannot  be  easily 
described,  and  is  to  be  learned  only  by  experience. 

The  Duration  of  a  given  sound,  you  will  find  varying 
according  to  the  pitch  of  that  sound  ;  the  higher  the 
pitch,  the  shorter  the  duration,  and  vice  ver$d.  For  ex- 
ample, the  duration  of  the  percussion  sound  is  percept- 
ibly longer  in  the  infra-clavicular  region  of  a  healthy 
chest  than  over  the  heart. 

You  will  find  that  a  certain  definable  relationship  ex- 
ists between  these  respective  elements  of  the  percussion 
note,  which  has  a  correspondence  to  the  different  regions 
of  the  chest.     Thus,  after  noting  the  intensity,  pitch, 


PERCUSSION.  21 

quality,  and  duration  of  the  percussion  sound  in  the 
infra-clavicular  region,  you  will  find  that  over  the  heart 
it  has  a  higher  pitch  and  harder  quality,  but  a  less  inten- 
sity and  a  shorter  duration. 

The  substance  which  receives  the  stroke  in  mediate 
percussion  is  termed  a  pleximeter,  of  which  many  varie- 
ties have  been  devised,  made  of  wood,  ivory,  gutta 
percha,  etc.  They  are  in  nowise  superior,  however,  to 
the  left  index  or  middle  fingers,  when  their  palmar  sur- 
face is  applied  evenly  to  the  chest;  for  these,  besides  be- 
ing the  most  handy,  also  answer  best  the  chief  requisite 
of  a  pleximeter  in  that  they  can  be  easily  fitted  with 
accuracy  to  any  part  of  the  thoracic  walls.  Moreover, 
their  own  proper  sound,  on  being  struck,  is  inappreciable, 
which  is  not  the  case  with  ivory,  wood,  etc.  Likewise, 
you  will  discover  nothing  better  to  strike  with  than  the 
finger  tips  of  the  other  hand,  brought  into  line  ;  while, 
for  gentle  percussion,  the  middle  finger  alone  may  suf- 
fice. 

Now,  as  the  practice  of  percussion  requires  some 
manual  dexterity,  and  the  correctness  of  its  indications 
depends  in  great  measure  upon  the  mode  in  which  it  is 
performed,  you  will  find  it  useful  to  have  recourse  to 
the  following  rules  as  your  guides  : 

First.  You  should  attend  as  carefully  to  the  position 
of  your  patient  as  a  photographer  would,  if  he  were 
going  to  take  his  likeness.  Whether  lying,  sitting,  or 
standing,  his  body  should  rest  on  the  same  plane,  and 
his  limbs  be  disposed  similarly,  on  either  side,  so  as  tc 
render  the  muscular  tissue  covering  the  thoracic  walls 
equally  tense.  In  percussing  particular  regions,  how- 
ever, the  first  aim  is  to  make  the  intervening  tissue  as 
firm  and  thin  as  possible.  Thus,  when  you  percuss  the 
front  of  his  chest,  the  arms  should  hang  loosely  down, 


22  PHYSICAL   DIAGNOSIS. 

but  the  head  be  thrown  back.  On  the  contrary,  the 
arms  should  be  raised  to  the  level  of  the  head  when  you 
are  percussing  the  lateral  regions,  and  should  be  crossed 
in  front,  the  patient  leaning  moderately  forward,  when 
you  percuss  the  back.  It  is  better  to  percuss  on  the 
naked  skin,  but  various  considerations  may  make  this 
unadvisable.  You  should  then  aim  to  have  the  covering 
as  soft,  thin,  and,  especially,  as  even  as  possible. 

Second.  The  two  sides  of  the  chest  should,  for  com- 
parison, be  percussed  at  the  same  stages  of  the  respira- 
tory act.  You  should,  also,  take  care  to  compare  only 
corresponding  portions  in  the  two  sides.  Thus,  you 
should  not  compare  a  note  during  inspiration  on  the 
right  side  with  one  during  expiration  on  the  left,  nor 
that  over  a  rib  with  that  of  an  interspace. 

Third.  The  finger,  or  pleximeter,  should  be  applied 
with  equal  firmness,  and  in  the  same  parallel,  to  both 
sides  in  succession,  and  the  force  of  the  percussion 
should  be  exactly  the  same ;  for  the  sound  will  vary 
considerably  even  on  the  same  spot,  whether  you  press 
lightly  or  firmly  with  your  finger,  whether  it  is  across  a 
rib  or  along  it,  and,  finally,  whether  you  strike  gently  or 
forcibly. 

Fourth.  The  stroke  in  percussion  should  be  made 
from  the  wrist  alone,  the  arm  and  forearm  not  partici- 
pating in  it ;  and  its  force  should  be  proportioned  to  the 
depth  of  the  part  to  be  examined — gentle  if  superficial, 
and  forcible  when  deep  seated. 

Percussion  in  Health. — The  significance  of  the  per- 
cussion sounds  in  disease  depends  so  entirely  on  their 
variation  from  the  sounds  which  are  proper  to  the  part 
in  health,  that  you  cannot  pay  too  much  attention  to 
the  various  characters  of  normal  thoracic  percussion  ; 
for  on  this  almost  every  deduction  which  results  from 


PERCUSSION.  23 

your  examination  is  based.  Now,  the  percussion  sounds 
differ  materially  in  a  healthy  thorax,  according  to  the  re- 
gion percussed.  Taking  the  percussion  note  of  the  infra- 
clavicular region  as  the  standard  for  pulmonary  percus- 
sion, we  find  each  of  the  other  regions  has  its  own 
variations  from  it.  In  the  right  infra-mammary  region 
you  will  get,  by  gentle  percussion,  the  same  note  as  in 
the  infra-clavicular  ;  but  forcible  percussion,  at  and  be- 
low the  fourtn  interspace,  will  raise  the  pitch  and  har- 
den the  quality,  owing  to  the  presence  of  the  liver  be- 
hind the  shelving  border  of  the  lung.  Over  the  left 
infra-mammary  region  the  pitch  is  similarly  varied  by 
the  presence  of  the  heart,  until  it  reaches  complete  flat- 
ness at  its  inner  border.  The  resonance  of  the  right 
infra-mammary  region  has  a  harder  quality,  higher 
pitch,  and  shorter  duration,  from  the  presence  of  the 
liver  immediately  beneath.  The  left  infra-mammary  re- 
gion is  similarly  affected  at  its  inner  part  by  the  left  lobe 
of  the  liver,  and  at  its  outer  border  by  the  spleen,  while 
the  intermediate  space  gives  a  tympanitic  resonance 
from  the  subjacent  stomach.  Over  both  clavicles  you 
will  get  a  mixed  pulmonary  and  osseous  resonance, 
while  in  the  supra-sternal  region  the  percussion  sound 
has  a  distinctly  tubular  character.  In  the  superior  ster- 
nal region  it  has  a  bony  tubular  resonance  down  to  the 
second  rib  ;  below  this,  to  the  third  rib,  it  is  raised  in 
pitch  and  hardened  in  quality.  The  dulness  on  percus- 
sion becomes  complete  in  the  next  region,  or  inferior 
sternal,  owing  to  the  presence  of  the  heart  and  great 
vessels,  together  with  the  left  lobe  of  the  liver. 

The  Superior  and  Middle  Axillary  regions  are  ex- 
tremely resonant  as  far  down  as  the  fourth  interspace  ; 
the  pitch  is  even  lower  than  in  .the  infra-clavicular  re- 
gion, but  below  the  fourth  interspace  the  pitch  rises,  till 


24  PHYSICAL   DIAGNOSIS. 

complete  dullness  is  found  on  a  level  with,  and  below,  the 
seventh  rib.  This  dulness  continues  through  the  infra- 
axillary  regions  on  either  side. 

In  the  Supra-Scapular  and  Scapular  regions  the 
percussion  sound  is  high-pitched  and  hard  in  quality, 
except  in  the  supra- spinous  fossae,  where  it  has  the  soft 
quality  characteristic  of  pulmonary  percussion.  In  the 
infra-scapular  region  you  have  pulmonary  resonance  as  <&r-LU 
'far  down  as  the  tenth  rib,  and  complete  flatness  below. 
In  the  inter -scapular  region  the  percussion  is  high- 
pitched  and  tubular  in  quality. 

Besides  variations  in  percussion  sounds  dependent  on 
difference  in  regions,  there  are  still  others  ascribable  to 
age,  sex,  idiosyncrasies,  etc.  You  will  find  the  percus- 
sion sound  in  children  of  a  softer  quality  and  lower 
pitch  than  in  adults  ;  while  in  the  aged  it  rises  in  pitch, 
and  measurably  loses  its  pulmonary  quality.  In  females 
the  percussion  sound  is  relatively  more  pulmonary  in  all 
its  characters  than  in  males.  Marked  deformity  of  the 
chest,  whether  congenital  or  acquired,  also  modifies  the 
normal  resonance.  But  it  also  varies  materially  in  differ- 
ent individuals  who  are  equally  healthy.  In  some  per- 
sons this  difference  may  be  accounted  for,  while  in  others 
it  cannot  ;  but,  as  a  rule,  the  thinner  the  chest  walls, 
the  greater  is  the  intensity,  the  lower  the  pitch,  and  the 
more  pulmonary  the  quality  of  the  percussion  sound. 

Percussion  in  Disease. —It  is  obvious,  from  what 
precedes,  that  whatever  modifies  the  density  of  the  lung 
substance,  and  changes  its  proper  elasticity,  will  cause 
a  corresponding  modification  in  the  normal  pulmonary 
resonance  ;  for  as  the  lung  texture  is  rendered  more 
dense,  or  less  so,  than  natural,  the  percussion  sound 
passes  through  every  gradation  from  marked  resonance 
to  complete  dulness.    These  modifications,  caused  by  dis- 


PERCUSSION.  25 

ease,  we  would  classify  under  the  following  heads,  viz. : 
Exaggerated  Pulmonary  Resonance,  Dulness,  Flatness, 
Tympanitic  Resonance,  Vesiculo- Tympanitic  Resonance, 
Amphoric  Resonance,  and  Cracked-Pot  Resonance. 

Exaggerated  Pulmonary  Besonance  consists  in  an 
increase  of  the  intensity  of  the  sound,  the  pitch  being 
slightly  lower,  while  the  quality  remains  unchanged. 
This  sign  may  exist  to  a  slight  degree  over  the  whole  or 
over  a  portion  of  a  lung  which  is  performing  more  than 
its  usual  share  of  labor.  Thus,  if  one  pleural  cavity  is 
filled  with  fluid,  or  if  one  lung  is  solidified  by  the  exu- 
dation of  pneumonia,  or  the  seat  of  extensive  tuberculous 
deposit,  you  will  find  the  resonance  of  percussion  in- 
creased on  the  opposite  unaffected  side,  which  is  now 
doing  double  duty.  Extensive  anaemia,  by  lessening  the 
quantity  of  blood  in  the  lungs,  may  also  give  rise  to 
slight  extra  resonance  on  percussion. 

Dulness. — This  consists  in  a  diminution  of  the  pulmo- 
nary resonance,  and  may  be  slight,  considerable,  or 
complete,  according  as  more  or  less  air  enters  the  af- 
fected part.  In  dulness  the  intensity  is  diminished,  the 
pitch  raised,  the  duration  shortened,  and  the  quality 
hardened.  Dulness  always  indicates  a  decrease  in  the 
normal  proportion  of  air  in  the  part,  and  is  an  impor- 
tant physical  sign  in  a  number  of  diseases,  as  in  pneu- 
monia, tuberculosis,  oedema  of  the  lungs,  etc. 

Flatness. — This  indicates  the  total  absence  of  air,  so 
that  there  is  no  proper  pulmonary  resonance,  and  its 
sound  resembles  that  produced  by  percussing  the  thigh. 
We  have  examples  of  this  when  we  percuss  over  liquid 
contained  in  the  pleural  or  pericardial  serous  cavities, 
or  when  tumors  are  developed  in  the  thorax,  etc. 

Tympanitic  Eesonance. — This  is  marked  by  the  ab- 
sence of  proper  pulmonary  quality  in  the  characters  of  its 


2G  PHYSICAL   DIAGNOSIS. 

resonance,  the  type  being  the  resonance  of  a  tympanitic 
abdomen  on  percussion  ;  in  intensity  it  exceeds  normal 
pulmonary  percussion,  and  is  lower  in  pitch.1  As  a 
physical  sign  in  thoracic  affections  it  usually  indicates 
the  presence  of  air  in  the  pleural  cavity,  as  in  pneumo- 
thorax. In  this  affection  we  have  air  contained,  not  in 
small  vesicles,  but  in  a  large  free  space,  and  hence  we  have 
not  the  Vesicular  but  the  tympanitic  quality  in  the  sound. 

Vesiculotympanitic  Eesonance. — By  this  term  (in- 
troduced by  Prof.  A.  Flint)  it  is  meant  to  denote  a  reso- 
nance in  which  we  have  both  the  tympanitic  and  vesicu- 
lar qualities.  It  is  lower  pitched  but  more  intense  than 
normal  pulmonary  resonance,  and  is  present  when  the 
increase  of  the  volume  of  the  lung,  as  in  some  cases  of 
emphysema,  is  so  great  as  to  dilate  and  render  extremely 
tense  the  thoracic  walls. 

Amphoric  Eesonance,  unlike  tympanitic  resonance 
(which  gives  an  impression  of  fulness),  is  suggestive  of 
shallowness  or  emptiness ;  it  resembles  the  sound  pro- 
duced by  flapping  the  cheek  when  the  mouth  is  closed, 
and  fully  but  not  forcibly  inflated.  It  is  most  frequently 
heard  over  a  large  superficial  cavity  having  thin,  tense 
walls,  and  hence  is  usually  indicative  of  phthisis.  In 
cases  of  pleuro-pneumonia,  a  sound  more  or  less  amphoric 
in  character  is  sometimes  heard. 

Cracked-Pot  Eesonance  is  usually,  though  not  in- 
variably, heard  in  connection  with  amphoric  resonance. 
It  resembles  the  sound  produced  by  striking  the  hands, 
loosely  folded  across  each  other,  against  the  knee,  the 
contained  air  being  suddenly  forced  out  between  the  fin- 
gers.    If  there  exists  a  pulmonary  cavity  of  large  size, 

1  Many  authorities  speak  of  the  pitch  as  raised.  I  regard  it  lower 
than  normal.  But  pitch  is  not  an  essential  element.  We  recog- 
nize the  tympanitic  sound  by  its  quality,  not  its  pitch. 


PERCUSSION.  'Z7 

with  tliin  walls,  communicating  freely  with  a  large 
bronchial  tube,  the  chest  walls  being  at  the  same  time 
particularly  yielding,  forcible  percussion,  with  the  pa- 
tient's mouth  open,  will  yield  cracked-pot  resonance. 
Dr.  Hughes  Bennett  states  that  a  cracked-pot  reso- 
nance may  be  elicited  in  various  diseases  of  the  chest,  and 
even  when  the  chest  is  perfectly  sound.  I  have  never 
obtained  true  cracked-pot  resonance  unless  over  a  pul- 
monic cavity  or  in  pneumothorax. 

Auscultatory  Percussion. — This  is  a  combination  of 
auscultation  and  percussion.  It  was  first  brought  to 
the  notice  of  the  profession  by  Drs.  Cammann  and 
Clark  in  1840. 

Their  method  of  performing  it  was  as  follows :  Press 
the  objective  end  of  a  stethoscope,  constructed  expressly 
for  this  purpose '  (while  the  ear  piece  is  accurately  fitted 
to  the  ear),  firmly  and  evenly  on  the  surface,  directly 
over  that  portion  of  the  organ  or  tumor  to  be  examined 
which  is  most  superficial  ;  then  let  percussion  be  per- 
formed in  the  usual  way,  one  or  two  inches  from  the 
point  at  which  the  stethoscope  is  applied.  The  percus- 
sion sound  communicated  to  the  ear  in  this  manner  far 
exceeds  in  intensity  and  distinctness  the  same    sound 

1  This  instrument  is  a  solid  cylinder  of  "wood,  shaped  in  the  direc- 
tion of  the  woody  fibres,  six  inches  in  length  and  ten  or  twelve 
lines  in  diameter  ;  furnished  with  an  ear  piece  which  will  allow 
nearly  the  whole  cylinder  to  pass  through  it,  so  that  it  may  apply 
directly  to  the  tube  of  the  ear,  without  change  of  medium.  To 
avoid  as  much  as  possible  the  sound  of  the  thoracic  walls,  as  is  de- 
sirable in  some  cases,  this  instrument  has  been  modified  by  reduc- 
ing it  at  its  objective  extremity  to  a  truncated  wedge,  leaving  the 
other  extremity  as  before.  This  is  applied  between  the  ribs  so  as 
not  to  touch  them,  and  at  the  same  time  approach  somewhat  nearer 
the  object  under  examination. — New  York  Journal  of  Medicine  and 
Surgery,  July,  1840. 


28  PHYSICAL   DIAGNOSIS. 

when  communicated  through  the  medium  of  tne  air. 
The  slightest  change  in  pitch  and  quality  is  also  readily- 
appreciated. 

The  benefits  claimed  for  auscultatory  percussion  by  its 
originators  are  :  "  First.  That  the  heart  can  be  measured 
in  all  but  its  antero-posterior  diameters,  under  most, 
perhaps  all  circumstances  of  health  and  disease,  with 
hardly  less  exactness  than  we  should  be  able  to  do  if  the 
organ  were  exposed  before  us. 

"  Second.  That  the  outlines  of  the  liver  can  be  traced 
with  much  greater  certainty  than  by  ordinary  percus- 
sion, in  circumstances  of  health  ;  and  to  circumscribe  it 
in  many  conditions  of  disease  in  which  ordinary  percus- 
sion is  not  applicable. 

"  Third.  That  the  dimensions  of  the  spleen  can  be 
ascertained  in  circumstances  that  baffle  ordinary  per- 
cussion. 

' '  Fourth.  That  by  it  we  can  mark  the  superior,  infe- 
rior, and  external  limits  of  the  kidneys.  Ascites  pre- 
sents no  obstacle  to  the  measurement  of  these  organs  ; 
and  from  enlarged  spleen  the  left  kidney  is  easily  dis- 
tinguished." 

Succussion  is  the  sudden,  forcible  shaking  of  the  pa- 
tient while  your  ear  is  applied  to  the  chest  wall.  It  is 
employed  almost  exclusively  in  the  diagnosis  of  one  dis- 
ease, viz.,  pneumo-hydrothorax.  The  sound  produced 
resembles  that  perceived  on  shaking  a  bottle,  partly  filled 
with  water,  close  to  the  ear.  It  is  a  gurgling,  splashing 
sound,  and  varies  in  tone  according  to  the  density  of  the 
fluid  present  and  the  relative  quantities  of  fluid  and  air 
present.  Succussion  is  almost  always  accompanied  by 
amphoric  respiration  and  metallic  tinkling.  I  shall  re- 
serve its  further  consideration  until  I  detail  the  physical 
signs  of  pneumo-hydrothorax. 


LESSOR    IT. 

AUSCULTATION. 

Auscultation  is  a  kind  of  eavesdropping,  for  in  it 
you  bend  your  ear  to  catch  the  significance  of  sounds 
that  come  from  hidden  quarters  which  no  one  may 
open.  As  in  percussion,  so  here,  auscultation  may  be 
immediate,  when  the  ear  is  applied  directly  to  the  bared 
or  thinly  covered  surface  ;  and  mediate,  when  the  sounds 
are  conducted  from  the  surface  to  the  ear  through  a  tu- 
bular instrument,  called  a  stethoscope. 

Both  of  these  methods  have  their  exclusive  advocates, 
but,  as  each  has  its  own  advantages,  I  would  strongly 
recommend  your  becoming  equally  practised  in  the  use 
of  them  both.  Per  se,  immediate  auscultation  answers 
best  for  pulmonary  examinations  ;  but  in  examining 
the  heart,  where,  as  in  valvular  murmurs,  you  have  to 
analyze  circumscribed  sounds,  your  ear  will  often  be 
confused  by  the  noise  of  its  near  neighbor,  the  left  lung, 
or  by  other  cardiac  sounds  than  the  one  under  exami- 
nation, and  you  will  find  the  stethoscope  then  assists 
you  by  measurably  excluding  the  sounds  which  have 
their  seat  outside  the  rim  of  the  chest  piece.  Besides, 
there  are  cases  where  the  state  of  the  surface  may  make 
you  very  reluctant  to  bring  your  ear  into  immediate 
contact  with  the  patient's  person,  while  in  other  cases 
you  may  not  be  allowed  to  do  so,  and  in  such,  of  course, 
you  would  have  recourse  to  the  stethoscope. 

Stethoscopes  of  great  variety  as  to  form  and  material 


30  PHYSICAL   DIAGNOSIS. 

have  been  recommended,  each  inventor  claiming  some 
superiority  in  principle,  or  shape,  for  his  own  instrument. 
They  may  all,  however,  be  referred  to  two  general 
classes,  viz.,  flexible  and  solid.  I  regard  as  the  best  rep- 
resentatives of  these  two  classes  those  devised  by  the 
late  Dr.  Cammann,  of  this  city.  For  general  use  I 
would  recommend  his  Binaural  Stethoscope.  It  con- 
sists of  two  tubes,  the  lower  extremities  of  which  are 
connected  to  a  cup-shaped  piece  of  wood  or  hard  rubber. 
It  requires  some  practice  to  become  adepts  in  its  use,  as 
it  indiscriminately  intensifies  all  sounds  ;  but  once  ac- 
customed to  it,  you  will  find,  I  think,  it  has  no  superior. 

In  the  performance  of  auscultation,  as  of  percussion, 
certain  precautions  are  requisite  in  order  to  insure  accu- 
rate results.  The  following  rules  will  be  found  of  ser- 
vice : 

First.  In  immediate,  but  not  in  mediate  auscultation, 
the  chest  should  have  some  thin,  soft  covering  which 
will  not  interfere  with  the  transmission  of  sound,  or  it- 
self produce  sound  from  the  movements  of  the  thoracic 
walls  to  which  it  is  applied.  A  soft  towel  smoothly 
spread  over  the  surface  will  answer  this  purpose  very 
well. 

Second.  The  position  of  the  patient  should  be  regu- 
lated in  the  same  manner  as  for  the  performance  of  in- 
spection, care  being  taken  that  the  parts  should  be  in  a 
state  of  perfect  repose.  The  position  of  the  examiner 
should  be  as  unrestrained  as  possible,  and  he  should  by 
all  means  learn  to  concentrate  his  attention  on  the 
sounds  which  reach  his  ear. 

Third.  The  ear,  or  the  stethoscope,  should  be  applied 
firmly,  but  not  forcibly,  to  the  surface ;  and,  when  the 
stethoscope  is  used,  it  is  important  that  its  rim  press 
equally  and  evenly  on  the  part. 


AUSCULTATION.  31 

Fourth.  As  in  percussion,  corresponding  parts  of  the 
two  sides  of  the  chest  should  be  compared,  and  the  ex- 
amination should  not  be  considered  complete  unless  it 
has  included  the  entire  chest.  In  acute  thoracic  affec- 
tions auscultation  should  be  frequently  repeated. 

Fifth.  The  examination  should  be  commenced,  if  pos- 
sible, during  ordinary  respiration.  The  patient  should 
be  directed  to  take  a  full  inspiration,  then  to  cough,  and 
then  again  to  breathe  naturally.  Some  find  the  latter 
very  difficult,  when  under  examination,  and  they  some- 
times seem  incapable  even  of  completing  a  full  inspira- 
tion. In  such  instances,  our  object  may  be  attained  by 
performing  the  act  ourselves,,  and  requesting  the  patient 
to  imitate  it,  or  by  directing  him  to  sigh.  If  these  expe- 
dients fail,  direct  him  to  cough  continually  for  some 
moments,  whereupon  a  full,  clear  inspiration  follows, 
and  he  does  involuntarily  what  his  previous  efforts  have 
failed  to  accomplish. 

Let  us  now  consider  the  important  subject  of  the  na- 
ture and  causes  of  the  respiratory  sounds  in  health. 

If  the  ear  be  applied  to  a  healthy  chest,  a  soft,  breezy 
murmur  will  be  heard,  composed  of  two  periods — one 
corresponding  to  the  movements  of  inspiration,  and  the 
other,  both  fainter  and  shorter,  to  those  of  expiration. 
They  are  termed,  respectively,  the  inspiratory  and  the 
expiratory  sounds  of  respiration.  The  elements  of  these 
sounds  are  analogous  to  those  of  percussion,  and,  hence, 
we  express  them  by  the  terms  Intensity,  Pitch,  Quality, 
and  Duration,  to  which,  however,  we  add  a  fifth — 
Rhythm — which  refers  to  the  relative  succession  of  the 
two  periods  in  the  respiratory  act.  As  might  be  ex- 
pected, we  find  variations  among  these  elements,  nor- 
mally present  in  the  various  portions  of  the  respiratory 
tract,  and  these  constitute  distinct  varieties  of  respira- 


32  PHYSICAL  DIAGNOSIS. 

tory  sounds,  which  are  named  after  those  portions,  in 
which  they  occur  in  health.  Thus  we  speak  of  vesicu- 
lar, bronchial,  tracheal,  and  laryngeal  respiration,  each 
of  these  sounds  having  its  own  proper  intensity,  quality, 
pitch,  etc.  The  left  infra-clavicular  region  in  a  healthy 
chest  furnishes  the  purest  vesicular  respiration  ;  the 
inter-scapular  region,  the  best  normal  bronchial  respira- 
tion ;  and  by  placing  the  stethoscope  or  ear  over  the 
larynx  or  trachea,  you  will  hear  the  tracheal  and  laryn- 
geal breathing.  These  variations  in  the  intensity,  pitch, 
etc. ,  are  due  to  differences  in  the  volume  and  velocity  of 
the  current  of  air,  on  the  one  hand,  and,  on  the  other, 
to  the  nature  of  the  obstructions  which  it  meets  in  its 
entrance  to,  or  exit  from,  the  pulmonary  passages. 
Every  complete  respiratory  sound,  however,  retains  its 
division  into  inspiratory  and  expiratory  murmurs. 

Of  the  normal  respiratory  sounds,  that  which  stands 
first  in  importance  is  the  Vesicular.  The  best  represen- 
tative type  of  the  normal  vesicular  murmur  is  found  in 
the  left  infra-clavicular  space,  where  you  will  hear  dur- 
ing inspiration  a  sound  of  a  gentle  rustling  character, 
most  marked  at  the  end  of  the  act.  The  intensity  and 
duration  of  this  murmur  vary  in  healthy  persons,  and 
form  the  least  important  of  its  elements.  Its  pitch, 
however,  should  be  low.  The  expiratory  sound,  when 
present  (it  being  absent  in  four  out  of  five  healthy 
persons  when  their  attention  is  not  directed  to  their  re- 
spiration), is  much  shorter  than  the  inspiratory,  its  rela- 
tive duration  varying  in  different  individuals  ;  its  in- 
tensity is  less  than  in  inspiration,  its  pitch  higher,  and 
its  quality  harder  ;  the  breezy  or  vesicular  character  of 
the  inspiratory  sound  being  wanting.  These  two  sounds 
follow  each  other  so  closely  that  they  may  be  said  to  be 
continuous,  and  this  fact  is  itself  an  important  element 


AUSCULTATION.  33 

of  normal  vesicular  respiration.  It  should  be  noted 
here,  however,  that  the  normal  respiratory  sounds  do 
not  exactly  correspond  in  the  two  infra-clavicular  re- 
gions. On  the  right  side,  the  pitch  of  the  inspiratory 
sound  is  higher  than  on  the  left,  and  less  breezy  in 
quality,  while  the  expiratory  is  more  pronounced  and 
prolonged  in  duration.  This  disparity  should  be  taken 
into  account  in  all  doubtful  cases,  such  as  in  suspected 
small  pulmonary  consolidations.  Age  affects  the  char- 
acter of  normal  vesicular  respiration,  taking  for  the 
standard  of  comparison  the  respiratory  sounds  in  healthy 
middle-aged  individuals.  In  infancy  the  intensity  of 
both  the  inspiratory  and  expiratory  sounds  is  increased, 
while  the  other  elements  remain  the  same.  In  old  age, 
on  the  other  hand,  the  intensity  is  diminished,  the  du- 
ration of  the  inspiratory  sound  shortened,  and  the  ex- 
piratory prolonged.  Sex  also  modifies  the  respiratory 
sounds.  As  a  rule,  the  inspiratory  and  expiratory 
sounds  have  greater  intensity  in  the  female  than  in  the 
male.  The  greatest  intensity  is  in  the  upper  anterior 
portions  of  the  chest  in  the  female,  while  in  the  male  it 
is  most  marked  in  the  lower  and  posterior  portions. 

If  the  ear  or  stethoscope  be  applied  to  the  larynx  or 
trachea,  two  sounds  will  be  heard,  one  with  inspiration, 
the  other  with  expiration.  These  sounds  constitute  the 
normal  laryngeal  and  tracheal  respiration.  It  differs 
from  the  normal  vesicular  respiration  in  that  its  in- 
tensity is  increased,  its  pitch  raised,  and  its  quality 
wholly  tubular.  The  inspiratory  sound  does  not  con- 
tinue quite  to  the  end  of  the  inspiratory  act,  so  that  an 
interval  occurs  between  it  and  the  expiratory  sound. 

The  characters  of  the  next  variety,  or  bronchial  respi- 
ration, are  very  important  to  the  auscultator  from  their 
common  occurrence  and  significance  in  disease.     They 
3 


34  PHYSICAL   DIAGNOSIS. 

are  those  of  tracheal  respiration,  only  in  a  less  marked 
degree,  being  less  tubular  in  quality,  while  the  interval 
between  the  inspiratory  and  expiratory  sounds  is  shorter. 
Now,  the  more  thoroughly  you  learn  these  varieties 
of  healthy  respiration,  the  better  you  will  be  prepared 
to  understand  what  respiratory  sounds  are  abnormal. 
Very  often  you  will  hear  in  disease  what  you  recognize 
as  one  of  the  normal  sounds,  but  you  know  that  this 
familiar  sound  has  in  this  case  a  serious  import,  because 
it  is  not  the  natural  sound  of  that  locality.  But  you 
may  also  hear  sounds  whose  character  differs  from  any 
normal  type.  We  may  say,  in  general,  that  abnormal 
sounds  consist  in  changes  from  the  standard  of  healthy 
respiration  as  regards  the  three  elements  of  intensity, 
rhythm,  and  quality,  thus  : 

_     _  .  .  f  1.  Exaggerated  or  increased. 

In  Intensity  the  respira-      j  g    Diminished  or  feeble 

•^  ^  I  3.  Absent  or  suppressed. 


In  Rhythm  the  respira- 
tory murmur  may  be  . 


1.  Interrupted. 

2.  The  interval    between    inspiration 
and  expiration  be  pi'olonged. 

3.  Expiration  be  prolonged. 

j  1.  Rude,  termed  rude  respiration. 

In  Quality  the  respira-      J  2.  Bronchial,       "       bronchial     " 
tory  murmur  may  be. . .    j  3.  Cavernous,      "       cavernous    " 
[  4.  Amphoric,       "       amphoric     " 

Alterations  in  Intensity. 

Exaggerated  Respiration  differs  from  the  normal 
vesicular  respiration  only  in  an  increase  in  the  intensity 
and  duration  of  the  respiratory  sounds.  It  is  sometimes 
called  puerile  respiration,  from  its  resemblance  to  the 
respiration  of  children.  It  occurs  in  a  part  where  respi- 
ration is  more  active  than  usual,  owing  to  deficient  ac- 
tion elsewhere,  as  in  the  upper  part  of  one  lung  whose 


ALTERATIONS   IN   RHYTHM.  35 

lower  lobe  is  consolidated  by  pneumonia,  or  similarly 
where  one  lung  does  the  duty  of  its  fellow  which  is  solid- 
ified by  the  pressure  of  a  pleuritic  effusion. 

Diminished  or  Feeble  Eespiration  differs  from  nor- 
mal vesicular  respiration  only  in  a  diminution  in  the  in- 
tensity and  duration  of  the  respiratory  sounds.  It  may 
arise  from  any  cause  which  interferes  directly  or  indi- 
rectly with  the  expansion  of  the  lung,  or  which  dimin- 
ishes the  elasticity  of  the  alveolar  walls.  Of  the  first 
condition,  we  have  illustrations  in  affections  which  re- 
strain the  movements  of  the  thoracic  walls,  as  pleuritic 
pain,  rheumatism,  paralysis,  etc. ;  or  when  there  is  some 
obstruction  to  the  entrance  of  air  into  the  lungs,  such  as 
in  diseases  of  the  larynx,  trachea,  or  bronchial  tubes  ;  or, 
again,  when  a  pleuritic  effusion  or  a  tumor  presses  the 
lungs  back  from  the  chest  walls,  though  not  to  a  degree 
sufficient  to  prevent  all  air  from  entering  them.  Of  the 
second  condition,  we  have  examples  in  pulmonary  em- 
physema and  in  incipient  tubercular  deposits. 

Absent  or  Suppressed  Respiration  occurs  whenever, 
from  some  cause,  the  play  of  the  lung  is  suspended. 
This  may  be  either  from  external  pressure,  as  when  the 
lung  is  forced  against  the  spinal  column  by  the  presence 
of  fluid  or  air  in  the  pleural  cavity  ;  or  when  a  complete 
obstruction  of  any  bronchus  prevents  the  air  from  either 
entering  or  leaving  the  lungs. 

Alterations  in  Rhythm. 

Interrupted  Respiration. — In  health  the  respiratory 
sounds  are  even  and  continuous,  with  a  brief  interval 
between  each  act.  This  may  be  altered  in  disease,  and 
Doth  sounds,  especially  the  inspiratory,  may  have  an 
interrupted  or  jerking  character,  termed  by  some  "  cog- 
wheel respiration."    We  have  examples  of  this  kind  of 


36  PHYSICAL   DIAGNOSIS. 

respiration  in  asthma,  pleurodynia,  first  stage  of  pleurisy, 
and  incipient  phthisis.  It  is  most  frequently  associated 
with  phthisis,  and  may  be  due  probably  to  some  gelati- 
nous mucus  adhering  to  the  walls  of  the  finer  bronchial 
tubes,  which,  though  not  sufficient  to  produce  rales,  still 
obstructs  the  free  ingress  and  egress  of  the  air. 

Prolonged  Interval  between  Inspiration  and  Ex- 
piration.— Instead  of  the  two  sounds  closely  succeeding 
one  another,  they  may  be  separated  by  a  distinct  inter- 
val. When  this  occurs,  either  the  inspiratory  sound  is 
shortened,  or  the  expiratory  delayed  in  its  commence- 
ment. In  the  first  instance,  it  is  the  result  of  pulmonary 
consolidation,  as  in  tubercle  ;  in  the  second,  the  elasticity 
of  the  pulmonary  tissue  is  impaired,  as  in  emphysema, 
no  sound  being  heard  during  the  first  portion  of  the  ex- 
piratory act. 

Prolonged  Expiration. — Here  the  ratio  between  nor- 
mal inspiration  and  expiration  is  inverted.  The  ex- 
piration, at  times,  is  twice  or  three  times  as  long  as  the 
inspiration. 

It  is  always  due  to  a  want  of  freedom  in  the  egress  of 
air  from  the  lungs.  The  most  common,  and  therefore, 
practically  speaking,  the  most  important,  cause  of  pro- 
longed expiration  is  tubercular  deposit  in  the  lung.  Ex- 
cessively prolonged  expiration  is  to  be  met  with  in  vesic- 
ular emphysema,  and  this  is  to  be  distinguished  from  the 
prolonged  expiration  of  phthisis  by  its  pitch,  which  in 
emphysema  is  low,  lower  than  the  inspiration,  while  in 
phthisis  it  is  high,  higher  than  the  inspiration,  and  tubu- 
lar in  quality. 

Alterations  in  Quality. 

Eude  Eespiration. — This  is  termed  by  Prof.  A.  Flint 
broncho-vesicular  respiration.     In  this  variety  both  in- 


ALTERATIONS    IN    QUALITY.  37 

spiratory  and  expiratory  sounds  lose  their  natural  soft- 
ness ;  the  breezy  or  vesicular  quality  is  lost ;  the  sounds 
are  higher  pitched  and  more  tubular  in  character,  while 
the  expiration  has  more  intensity,  higher  pitch,  and 
longer  duration  than  the  inspiration.  Rude  respiration 
always  indicates  more  or  less  consolidation  of  lung  tissue. 
In  normal  vesicular  respiration,  the  sounds  produced  by 
the  vibrations  of  the  air  in  the  air  cells  and  finer  bronchi 
obscure  that  produced  in  the  trachea  and  larger  bronchial 
tubes  (healthy  lung  substance  being  a  poor  conductor 
of  sound) ;  but  so  soon  as  any  portion  of  lung  be- 
comes consolidated,  the  vesicular  element  of  the  respi- 
ratory sound  is  diminished  and  the  bronchial  element 
becomes  prominent ;  this  change  constitutes  rude  respi- 
ration. It  embraces  every  degree  of  modification  between 
complete  bronchial  respiration  on  the  one  hand  and 
normal  vesicular  breathing  on  the  other,  the  increase  in 
bronchial  characters  corresponding  with  the  degree  of 
consolidation.  Rude  respiration  is  of  practical  value 
principally  in  the  diagnosis  of  incipient  phthisis. 

Bronchial  Respiration  is  characterized  by  an  entire 
absence  of  all  vesicular  quality.  The  inspiratory  sound 
is  high-pitched  and  tubular  in  character  ;  the  two  sounds 
are  separated  by  a  brief  interval ;  the  expiratory  is  still 
higher  pitched  and  more  intense  than  the  inspiratory,  is 
as  long  or  longer,  and  of  the  same  tubular  quality. 
Whenever  this  modification  of  the  respiratory  sound  is 
present,  where  in  health  normal  vesicular  murmur  should 
be  heard,  consolidation  of  lung  substance  may  be  in- 
ferred. Consequently  it  is  an  important  diagnostic  sign 
in  many  pulmonary  affections,  such  as  pneumonia,  pul- 
monary tuberculosis,  pulmonary  apoplexy,  etc. 

Cavernous  Respiration. — In  some  respects  this  re- 
sembles bronchial  respiration,  and  it  is  often  difficult  to 


38  PHYSICAL  DIAGNOSIS. 

distinguish  one  from  the  other.  Some  distinguished 
auscultators  declare  that  this  sign  does  not  exist. 

Its  distinguishing  characteristics  are,  on  inspiration,  a 
soft,  blowing,  low-pitched  sound,  non-vesicular  in  cha- 
racter :  as  a  rule,  the  expiratory  sound  is  lower  pitched 
than  the  inspiratory,  and  is  always  prolonged  and 
puffing. 

For  its  production,  there  must  be  a  cavity  of  consider- 
able size  in  the  lung  substance,  having  free  communica- 
tion with  a  bronchial  tube.  The  cavity  must  be  empty 
and  near  the  surface,  its  walls  must  be  sufficiently  flaccid 
to  expand  with  inspiration,  and  collapse  with  expiration. 
This  sign  is  most  frequently  met  with  in  the  advanced 
stage  of  pulmonary  tuberculosis. 

Amphoric  Eespiration. — Whenever  the  respiratory 
sound  has  a  musical  intonation  or  metallic  quality,  re- 
sembling that  produced  by  blowing  gently  into  the  mouth 
of  an  empty  bottle,  it  is  called  amphoric. 

The  amphoric  character  accompanies  both  acts  of  res- 
piration, especially  the  expiratory. 

It  may  be  due  to  phthisical  or  other  excavations  in  the 
lung  substance,  or  to  an  opening  from  the  bronchial  tube 
into  the  pleural  cavity,  giving  rise  to  pneumothorax. 
In  both  cases  the  sound  is  produced  by  vibrations  of  air 
in  a  cavity,  which  are  excited  by  a  current  of  air  from  a 
bronchial  tube.  The  cavity  in  the  lung  substance  which 
gives  rise  to  amphoric  respiration  must  be  of  large  size, 
empty,  with  tense,  firm  walls  so  as  not  to  collapse  with 
expiration,  and  it  must  communicate  freely  with  a  large 
bronchial  tube. 

This  sign  is  mainly  of  importance  in  the  diagnosis  of 
advanced  tuberculosis  and  pneumothorax. 

This  completes  the  history  of  the  most  important 
alterations  in  the  natural  respiratory  sounds  produced 


INTRA-THORACIC   AUSCULTATION.  39 

by  disease.  With  few  exceptions  they  are  not  new 
sounds,  but  are  heard  in  the  healthy  chest,  and  become 
significant  of  disease  only  when  heard  in  unnatural 
locations. 

A  new  method  of  auscultation  has  recently  been  proposed  by 
D».  B.  W.  Richardson  (vide  Lancet,  November  5th,  1892).  It  is 
termed  ' '  Intra-thoracic  Auscultation :  A  New  Departure  in  Physical 
Diagnosis."  He  employs  "a  good-sized  [oesophageal]  tube  with  a 
large  lateral  aperture  at  the  extreme  end.  Apertures  are  essential 
in  these  tubes;  if  they  are  not  made,  there  is  little  or  no  conduction 
of  sound/'  The  free  end  of  the  tube  is  connected  to  an  ordinary 
binaural  stethoscope.  Dr.  Richardson  claims  that  by  this  means 
an  early  diagnosis  of  stricture  of  the  oesophagus  can  be  made  from 
the  friction  sound  produced  as  the  tube  passes  over  the  induration, 
and  that  it  may  be  of  service  in  the  diagnosis  of  diseases  of  the  stom- 
ach itself  ;  that,  through  the  stomach,  pulsating  abdominal  tumors 
could  be  diagnosed  :  "with  the  terminal  of  a  full-sized  oesophageal 
stethoscope  in  the  stomach  cavity,  a  loud  murmur  from  an  arterial 
source  will  be  detected  without  the  interposition  of  pressure,  and  an 
important  difficulty  in  diagnosis  removed"  ;  and  that  this  method 
will  prove  of  service  in  the  diagnosis  of  diseases  of  the  heart  and 
aneurisms  of  the  large  thoracic  arterial  trunks.  In  concluding  he 
says  :  "I  assume  at  once  that  this  mode  of  research  is  not  called  for 
when  by  the  ordinary  auscultation  diagnosis  is  clear." 

I  have  not  tried  this  method  of  examination,  and  therefore  oannot 
recommend  it  from  personal  experience. 


LESSON  V. 


ABNORMAL  OR  ADVENTITIOUS  SOUNDS. 

The  sounds  which  are  now  to  be  considered  are  termed 
Adventitious,  because  they  are  not  heard  in  health,  but 
are  found  in  disease,  either  accompanying  the  normal 
respiratory  sounds,  or  wholly  supplanting  them.  They 
vary  much  in  their  character,  according  to  their  origin, 
that  is,  whether  they  are  caused  by  changes  in  the  lung 
itself  or  in  its  investments  ;  and,  hence,  in  order  to  ap- 
preciate their  significance  you  should  know  well  their 
seat  and  mode  of  production. 

The  sounds  which  originate  in  the  air  passages,  or 
in  cavities  abnormally  communicating  with  them,  are 
called  rales,  or  rhonchi ;  those  which  originate  in  the  in- 
vestments of  the  lung  are  called  pleuritic  friction  sounds. 
In  speaking  of  the  former  I  shall  use  the  term  rale,  and 
would  classify  the  varieties  which  we  meet  in  practice 
as  follows ; 


Rales. 


Dry  rales. 


Moist  rales.  •< 


Sonorous  rales. 
Sibilant  rales. 

Mucous  rales  (large  and  small). 
Sub -crepitant  rales. 
Crepitant  rales. 

Gurgles  (large  and  small). 
Mucous  click. 


A  rale  may  originate  in  the  trachea,  in  the  bronchi, 
large  or  small,  in  the  air  cells,  or  in  abnormal  cavities 
situated  either  within  or  without  the  lung  substance. 


RALES. 


41 


It  may  be  produced  within  the  air  tubes,  either  by  a 
diminution  of  their  calibre,  by  the  vibrations  of  viscid 
matter  collected  in  them,  or  by  the  air  bubbling  through 
fluid  present  in  the  bronchi  and  in  the  air  vesicles,  or  in 
larger  or  smaller  cavities.  A  rale  may  be  either  dry  or 
moist  in  its  character,  and  may  be  audible  either  in  in- 
spiration or  in  expiration,  or  in  both. 

Dry  Rales  are  divided  into  sibilant,  and  sonorous  ac- 
cording to  the  pitch  and  quality  of  the  sound  ;  if  a  rale 


Sibilant  rales 

Subcrepitant  rales 

Sonorous  rales 
Mucous  rales 


Large 
sonorous 

rales 


Fig.  3.— Diagram  illustrating  the  Physical  Signs  of  Bronchitis. 


is  high-pitched  and  whistling,  it  is  termed  sibilant  ;  if 
low-pitched  and  snoring  in  character,  it  is  termed  sono- 
rous. 

The  Sibilant  rale  may  be  heard  during  both  inspira- 
tion and  expiration.  It  recurs  irregularly,  and  some- 
times is  so  high-pitched  as  to  become  hissing  in  its  char- 
acter. Its  seat  is  the  smaller  bronchi,  and  it  is  caused 
either  by  the  narrowing  of  these  tubes  from  thickening 
of  the  mucous  tissues  liniDg  them,  or  from  the  spas- 
modic contraction  of  their  muscular  coat ;    or  it  may  be 


42  PHYSICAL  DIAGNOSIS. 

owing  to  the  vibrations  of  viscid  mucus  adhering  to 
their  walls.  In  most  instances  it  may  be  temporarily 
removed  by  violent  coughing. 

The  Sonorous  rale  may  also  be  heard  during  both  in- 
spiration and  expiration.  As  above  mentioned,  it  is  a 
low-pitched,  snoring  sound,  which  varies,  however,  in 
intensity  from  a  slight  rale  to  one  loud  enough  to  be 
audible  at  a  distance  from  the  chest.  It  has  for  its  seat 
the  larger  bronchial  tubes,  and  is  produced  by  conditions 
of  those  tubes  similar  to  those  which  cause  sibilant  rales 
in  the  smaller  bronchi,  namely,  lessened  calibre  from 
tumefaction  of  the  mucous  tissues,  or  from  spasmodic 
contraction,  or  from  pressure  on  the  tube  from  without, 
by  a  tumor,  an  exudation,  or  a  deposit ;  or  it  may  be 
owing  to  the  vibrations  of  a  thickened  fold  of  the  lining 
membrane,  or  of  viscid  mucus  adhering  to  the  wall. 
This  rale  is  specially  frequent  in  bronchitis  and  spas- 
modic asthma,  though  it  may  be  present  in  almost  every 
pulmonary  disease. 

Moist  Rales. — Under  this  head  may  be  included  the 
crepitant,  sub-crepitant,  and  mucous  rales. 

Crepitant  rales  consist  of  a  series  of  minute,  crackling 
sounds.  They  persist  at  the  spot  where  first  heard, 
and  do  not  shift  their  position  as  the  other  moist  rales. 
They  are  audible  only  toward  the  end  of  inspiration. 
There  are  several  views  as  to  the  production  of  these 
sounds  :  that  they  are  due  to  the  bubbling  of  air  through 
a  liquid  in  the  pulmonary  vesicles  or  terminal  bronchi- 
oles ;  that,  at  the  end  of  expiration,  a  viscid  secretion 
glues  the  walls  of  the  vesicles  together,  and  their  sepa- ' 
ration  on  inspiration  gives  rise  to  the  crackling  sound  ; 
and  that  they  are  produced  in  the  pleura  independently 
of  the  pulmonary  parenchyma.  This  rale  is  the  charac- 
teristic sign  of  pneumonia  in  the  first  stage,  though  it  is 


RALES.  43 

not  infrequent  in  some  forms  of  pulmonary  congestion, 
and  m  oedema  of  the  lungs. 

The  Sub-crepitant  rale  is  a  moist  bronchial  sound, 
caused  by  the  breaking  of  minute  air  bubbles  of  equal 
size  and  comparatively  few  in  number.  Its  seat  is  the 
smallest  bronchi,  and  the  liquid  through  which  the  air 
passes  may  be  mucus,  serum,  pus,  or  blood.  It  differs 
from  the  crepitant  rale  in  the  larger  size  of  the  bubbles, 
and  is  heard  in  expiration  as  well  as  in  inspiration.  This 
rale  is  present  in  a  number  of  affections.  When  heard 
on  both  sides  of  the  chest  posteriorly,  it  indicates  capil- 
lary bronchitis.  It  is  characteristic  of  the  resolving  stage 
of  pneumonia,  and  is  termed  the  "rale  redux."  When 
present  only  in  the  apex  of  a  lung,  it  indicates  commenc- 
ing tuberculosis.  It  accompanies  the  effusion  of  blood 
into  the  bronchial  tubes,  and  is  sometimes  present  in 
oedema  of  the  lungs. 

The  Mucous  rale  is  a  moist  bronchial  sound,  produced 
in  the  same  manner  as  the  sub-crepitant.  Its  seat  is  in 
the  larger  tubes,  and,  according  to  the  size  of  the  tube 
in  which  the  sound  originates,  it  i.j,  termed  the  fine  or 
coarse  mucous  rale.  Like  the  sub-crepitant  rale,  you 
may  hear  it  during  both  inspiration  and  expiration,  and 
it  is  modified,  or  entirely  removed,  by  the  act  of  cough- 
ing. Mucous  rales  occur  in  bronchitis  during  the  stage 
of  secretion  ;  in  bronchial  haemorrhage  ;  whenever  pus 
makes  its  way  into  the  air  passages  from  an  abscess — 
in  short,  whenever  the  bronchial  tubes  become  partially 
filled  with  liquid  of  any  kind.  If  these  rales,  whether 
fine  or  coarse,  are  restricted  to  a  circumscribed  space  at 
the  apex  of  a  lung,  they  indicate  that  the  bronchitis  is 
of  tubercular  origin. 

Gurgles  are  produced  in  large  or  small  cavities  partly 
filled  with  liquid,  below  the  level  of  which  a  bronchus 


44 


PHYSICAL   DIAGNOSIS. 


freely  opens.  The  sound  is  due  to  the  bubbling  of  air  up 
through  the  liquid.  It  is  a  moist  sound,  but  has  a  pe- 
culiar hollow,  metallic  quality.  Gurgles  may  be  heard 
both  in  inspiration  and  expiration,  and  according  to 
the  size  of  the  cavity  will  they  be  "large"  or  "  small." 
Small  gurgles  resemble  large  mucous  rales,  but  may  be 
distinguished  from  them  by  their  above-mentioned  hol- 
low, metallic  character. 

The  most  frequent  cause  of  pulmonary  cavities  is  the 


Gurgles. 


Fig.  4.— Cavernous  Respiration  and  Gurgles 

softening  and  expectoration  of  a  cheesy  pneumonia,  but 
they  may  be  owing  to  abscess,  gangrene,  perforating 
empyema,  and  excessive  dilatation  of  the  bronchial 
tubes.  When  pulmonary  cavities  exist  without  gurgles, 
it  may  be  due  to  the  filling  of  the  cavity  with  liquid,  or 
to  its  containing  no  liquid,  or  because  the  level  of  the 
liquid  is  below  the  opening  of  the  bronchial  tube. 

Mucous  Click. — This  is  a  single,  quick,  clicking  sound, 
not  removed  by  coughing,  and  which  resembles  an  iso 
lated  sub-crepitant  rale.     Authors  differ  as  to  the  theory 


PLEURITIC    FRICTION   SOUNDS. 


45 


of  its  production.  It  appears  to  me  to  be  due  to  the  sud- 
den and  forcible  passage  of  air  through  a  small  bron- 
chus, the  sides  of  which  have  been  brought  together  at 
one  or  more  points,  either  by  external  pressure  or  by  ag- 
glutination from  within  ;  as  when  a  consolidated  lobule 
presses  unequally  upon  a  bronchus,  and  excites  a  local 
inflammation  of  the  mucous  membrane  with  its  con- 
sequent viscid  secretion.  It  is  therefore  important  as  a 
symptom  of  incipient  tuberculosis. 


Pleuritic  friction  sound 


Flatness  on  percus- 
sion. Absence  of  vo- 
cal and  respiratory 
sounds. 


Fig.  5.— Roughening  of  the  Pleurae,  and  Slight  Pleuritic  Effusion, 

Pleuritic  Friction  Sounds. — In  health  the  smooth 
pleural  surfaces,  moistened  by  their  natural  secretion, 
play  noiselessly  upon  each  other  during  the  respiratory 
movements.  When  an  inflammation  roughens  one  or 
both  of  these  surfaces,  or  dries  up  their  natural  secretion, 
it  gives  rise  to  a  friction  which  produces  the  charac- 
teristic sounds  to  which  the  above  name  is  given. 
These  sounds  consist  of  ODe  or  of  a  series  of 
abrupt,  jerking,  rubbing  noises,   manifestly  superficial. 


46  PHYSICAL  DIAGNOSIS. 

and  which  are  commonly  heard  over  a  limited  extent  of 
surface.  They  vary  much  in  intensity,  from  a  sound 
scarcely  audible  to  one  of  extreme  loudness  ;  and  they 
usually  accompany  both  inspiration  and  expiration,  be- 
ing seldom  heard  with  expiration  alone. 

There  are  several  varieties  of  pleuritic  friction  sounds, 
termed,  respectively,  grazing,  rubbing,  grating,  creak- 
ing, and  crackling ;  all  of  which  belong  to  the  clinical 
history  of  pleurisy. 

The  grazing  variety  occurs  at  the  onset  of  pleurisy, 
when  dryness  of  the  membrane  is  the  only  change  yet 
produced.  As  soon  as  there  is  dulness  on  percussion,  it 
is  replaced  by  the  rubbing  variety,  and  therefore  is  of 
such  short  duration  that  it  is  not  often  heard,  but  may 
be  more  frequently  noticed  in  the  circumscribed  pleurisy 
which  often  accompanies  pulmonary  tuberculosis.  The 
other  varieties  are  the  forms  in  which  the  pleuritic  fric- 
tion sound  most  commonly  presents  itself  ;  and  they 
occur  both  in  the  stage  of  plastic  exudation  and  in  the 
stage  of  absorption. 

Sometimes  the  respiratory  sound  is  attended  by  sounds 
resembling  rales,  which  are  doubtful  both  as  to  their 
situation  and  significance. 

They  are  of  two  kinds  :  First,  creaking  sounds  not  in- 
frequently heard  at  the  apices  of  the  lungs,  produced 
either  by  the  creaking  of  pleuritic  adhesions  or  by  crepi- 
tations in  lung  tissue.  Second,  dry  crumpling  sounds, 
resembling  those  produced  by  inflating  a  dried  bladder, 
probably  (as  Laennec  supposed)  produced  by  the  forcible 
distention  of  large  air  sacs  in  emphysematous  lungs. 


LESSOR"  VI. 

AUSCULTATION   OF   THE   VOICE. 

This  is  another  method  of  obtaining  information  as  to 
the  condition  of  the  lungs  and  their  investing  mem- 
branes. It  is  based  on  the  fact  that  the  vibrations  of  the 
voice  are  not  transmitted  upward  only,  but  also  down- 
ward, through  the  trachea  and  bronchi,  to  all  parts  of 
the  lung.  The  resonance  thus  produced  varies  in  cha- 
racter according  to  the  situation  in  which  it  is  heard. 
The  different  varieties  are  named  after  the  parts  where 
they  occur  in  health. 

If  the  stethoscope  be  placed  over  the  larynx  or  tra- 
chea of  a  healthy  person  while  speaking,  the  voice  will 
be  transmitted  to  the  ear,  imperfectly  articulated,  and 
with  a  force,  intensity,  and  concentration  almost  pain- 
ful. This  is  called  natural  laryngophony  or  tracheo- 
phony. 

At  the  upper  part  of  the  sternum,  and  between  the 
spines  of  the  scapula,  it  is  heard  less  intense,  more  dif- 
fused, and  less  distinctly  articulated  ;  and  this  is  termed 
bronchophony.  But  when  you  listen  over  the  lung  sub- 
stance itself,  the  voice  sounds  become  distant,  diffused, 
and  without  any  approach  to  articulation.  This  is 
termed  normal  vocal  resonance.  Its  intensity  is  usually 
greater  on  the  right  than  on  the  left  side,  especially  in 
the  infra-clavicular  region,  but  it  varies  considerably  in 
this  respect  in  different  healthy  persons.  In  females 
there  is,  not  infrequently,  no  difference  in  the  two  sides. 


48  PHYSICAL   DIAGNOSIS. 

The  intensity  over  the  whole  chest  is  greater  in  those 
who  have  low-pitched  voices,  and  in  thin  than  in  fleshy 
persons.  You  cannot  rely  on  the  vocal  resonance  of  any 
one  region  of  the  chest  as  trustworthy  evidence,  by  itself, 
either  of  health  or  of  disease.  Its  indications  are  fur- 
nished only  by  comparisons  of  corresponding  parts  of 
the  two  sides,  after  allowance  is  made  for  natural  dif- 
ferences. 

In  making  your  examination  for  this  purpose  the  read- 
iest way  is  to  direct  the  patient  to  count  one,  two,  three, 
or  repeat  the  numeral  99.  The  modifications  of  the  vo- 
cal resonance  which  you  will  find  indicative  of  disease 
will  consist  of  changes  in  intensity.  1.  Its  intensity 
may  be  diminished  ;  or,  2,  it  may  be  increased  ;  and  I 
would  classify  them  as  follows  : 

1.  Diminished  j  a.  Vocal  sounds  may  be  weak  or  feeble. 

intensity.       [b.         "         "  "      "    suppressed  or  absent. 

a.  Vocal  sounds  may  be  simply  exaggerated. 

b.  The  resonance  may  be  of  the  character  termed 
Bronchophony . 

c.  The  resonance  may  be  of  the  character  termed 
Pectoriloquy. 

d.  The  resonance  may  be  of  the  character  termed 
Egophony. 

e.  The  resonance  may  be  of  the  character  termed 
Amphoric  Voice. 

The  varieties  included  under  the  head  of  diminished 
resonance  require  but  little  explanation.  The  vocal  re- 
sonance may  be  faint  or  altogether  wanting.  The  first  of- 
ten occurs  in  bronchitis  with  free  secretion  ;  in  plastic 
pleuritic  effusions,  and,  occasionally,  when  there  is  ex- 
treme pulmonary  consolidation.  There  is  absence  of  vo- 
cal resonance  in  pneumothorax  and  in  copious  serous 
pleuritic  effusion.  The  modifications,  however,  which 
accompany  increased  intensity  are  more  varied  and  com- 
plex. 


Increased 
intensity. 


VOCAL   RESONANCE.  49 

Exaggerated  Vocal  Eesonance  differs  from  normal 
vocal  resonance  only  in  a  slight  increase  of  intensity.  It 
denotes  a  moderate  amount  of  solidification  of  lung  tis- 
sue, and  is  chiefly  of  importance  in  the  diagnosis  of  tu- 
berculosis. 

The  characters  of  Bronchophony,  as  contrasted  with 
normal  vocal  resonance,  are  its  greater  intensity,  higher 
pitch,  peculiar  vibrating  quality,  and  approach  to  articu- 
lation of  the  voice  sounds.  When  heard  in  abnormal 
situations  it  has  the  same  significance  as  bronchial  res- 
piration, though  more  complete  consolidation  is  neces- 
sary for  the  production  of  bronchial  respiration  than 
bronchophony.  The  best  example  of  bronchophony  is 
met  with  in  the  second  stage  of  lobar  pneumonia. 

Pectoriloquy  (so  named  by  Laennec,  its  discoverer;  is 
a  complete  transmission  of  the  voice  to  the  ear.  The 
words  spoken  are  heard  distinctly  articulated.  It  closely 
resembles  the  resonance  heard  over  the  larynx,  and  is 
usually  limited  to  a  small  space  in  the  chest,  where  it 
also  may,  or  may  not,  have  a  hollow,  ringing  character. 
It  was  formerly  believed  always  to  indicate  the  presence 
of  a  pulmonary  cavity,  but  auscultators  are  now  agreed 
that  this  is  not  necessarily  the  case  in  every  instance,  but 
that  it  is  sometimes  simply  an  exaggerated  broncho- 
phony ;  the  only  distinction  between  these  two  being 
that  bronchophony  is  the  transmission  of  the  voice,  pec- 
toriloquy that  of  the  speech.  Well-defined  pectoriloquy 
is  not  a  common  phenomenon. 

Egophony  is  the  name  given  by  Laennec  to  another 
form  of  vocal  resonance,  which  is  distinguished  by  its 
tremulous,  nasal  character,  suggestive  of  the  bleating 
of  a  goat.  It  also  is  a  modification  of  bronchophony. 
Laennec  considered  it  a  sign  of  a  limited  amount  of 
serous  effusion  in  the  pleura,  over  solidified  lung.     It 


50  PHYSICAL   DIAGNOSIS. 

is  rarely  heard,  and  is  of  not  much  significance  when 
heard. 

Amphoric  Voice  is  a  term  applied  to  the  vocal  reso- 
nance whenever,  in  addition  to  its  being  of  a  hollow, 
metallic  character,  it  has  a  distinct  musical  intonation. 
This  musical  sound  follows  the  voice,  is  of  high  pitch, 
and  is  not  articulated  like  pectoriloquy.  It  is  sometimes 
produced  in  large  cavities  within  the  lung,  but  is  more 
particularly  a  sign  of  hydro-pneumothorax. 

In  addition  to  vocal  resonance,  we  have  a  "true  whisper 
resonance,  the  modifications  of  which  by  disease  may 
afford  us  some  valuable  hints  (as  was  first  pointed  out  by 
Prof.  A.  Flint).  If,  while  practising  auscultation  on  a 
person  in  health  (as  I  should  strongly  advise  you  to  do 
with  one  another  while  studying  this  subject),  you  direct 
him  to  count  in  a  loud  whisper,  you  will  usually  hear  a 
soft,  blowing  sound,  accompanying  each  whispered  word, 
which  varies  in  intensity  in  different  persons. 

As  a  rule,  it  is  heard  only  at  the  upper  portion  of  the 
thorax,  and  is  loudest  over  the  primary  bronchi.  Dr. 
Flint  calls  this  sound  the  normal  bronchial  whisper,  and 
he  classes  its  abnormal  modifications  into  exaggerated 
bronchial  ivhisper,  whispering  bronchophony,  whispering 
pectoriloquy,  cavernous  whisper,  and  amphoric  ivhisper. 

The  exaggerated  differs  from  the  normal  whisper  in 
having  greater  intensity  and  higher  pitch.  It  indicates 
slight  solidification  of  lung  tissue.  In  whispering  bron- 
chophony, the  blowing  sound  is  intense,  the  pitch  high, 
and  the  sound  seems  near  to  the  ear.  When  heard  in 
situations  where  it  is  not  normally  present,  it  indicates, 
like  vocal  bronchophony,  more  or  less  complete  consoli- 
dation of  the  lung  substance.  The  cavernous  whisper  is  a 
hollow,  low-pitched,  blowing  sound.  It  is  a  trustworthy 
indication  of  a  cavity,  and  requires  for  its  production 


RESONANCE   OF  COUGH.  51 

conditions  similar  to  those  which  give  rise  to  cavernous 
respiration.  In  whispering  pectoriloquy,  the  whispered 
words  are  distinctly  audible  at  the  surface  of  the  chest, 
and  this  constitutes  a  more  sure  indication  of  a  cavity 
than  vocal  pectoriloquy.  The  character  and  the  signi- 
ficance of  the  amphoric  whisper  are  the  same  as  those 
of  the  amphoric  voice. 

Another  of  the  adventitious  sounds  is  that  which  is 
termed  metallic  tinkling,  its  name  being  sufficieutly  de- 
scriptive of  its  character.  It  sounds  like  the  dropping  of 
a  pin  or  a  small  shot  into  a  metallic  vessel.  A  single 
one,  or  a  series  of  tinkling  sounds,  may  be  produced  by 
the  act  of  speaking,  or  by  the  movements  of  inspiration 
and  expiration  ;  but  it  is  especially  consequent  on  the 
act  of  coughing. 

This  sound  announces  the  existence  either  of  a  very 
large  pulmonary  cavity  or  of  hydro-pneumothorax.  Dr. 
Walsh  regards  it  as  the  echo  of  a  bubble  bursting  in  a 
liquid,  shut  up  in  a  spacious  cavity  which  also  contains 
air. 

Eesonance  of  Cough.  — In  a  healthy  individual,  the 
act  of  coughing  is  accompanied  by  a  quick,  sharp,  in- 
distinct sound,  which  jars  through  the  whole  chest. 
Over  the  larynx  and  trachea  the  cough  is  hollow,  and 
varies  in  pitch  and  intensity  with  the  voice  of  the  in- 
dividual. The  modifications  of  the  cough  sound  in  dis- 
ease are  termed  bronchial,  cavernous,  and  amphoric. 
Bronchial  cough  has  a  quick,  harsh  character,  attended 
by  a  marked  thrill  or  fremitus  of  the  chest.  Cavernous 
cough  is  hollow  and  metallic  (commonly  it  is  termed 
sepulchral).  It  may  be  accompanied  by  gurgles,  and  its 
resonance  is  sometimes  transmitted  to  the  ear  of  the 
auscultator  with  painful  intensity.  Amphoric  cough  is 
a  loud  resounding  sound,  of  metal] ic  character,  but  not 


52  PHYSICAL  DIAGNOSIS. 

forcibly  transmitted  to  the  ear.  It  conveys  the  impres- 
sion of  a  large  empty  space.  These  varieties  of  cough 
are  heard  under  the  same  conditions  as  the  correspond- 
ing varieties  of  respiration.  They  are  not  of  mucn 
utility  in  diagnosis. 


LESSON"  TIL 

A  SYNOPSIS   OF   PHYSICAL  SIGNS  IN   THE  DIAGNOSIS   OF 
PULMONARY  DISEASES. 

Bronchitis. 

Acute   and   Chronic  Bronchitis   affecting   the  Larger 

Tubes. 

Inspection.— The  form  and  movements  of  the  chest 
are  not  visibly  altered. 

Palpation. — Vocal  fremitus  is  normal ;  occasionally 
a  distinct  bronchial  fremitus  is  communicated  to  the  sur- 
face of  the  chest. 

Percussion. — Pulmonary  resonance  is  normal,  unless 
there  is  a  very  considerable  accumulation  of  mucus  in 
the  bronchial  tubes,  in  which  case  the  normal  resonance 
is  diminished  in  the  lower  and  posterior  regions. 

Auscultation. — The  respiratory  murmur  is  feeble  or 
temporarily  suppressed  in  the  lung  tissue  correspond- 
ing to  the  affected  tubes.  In  the  dry  stage,  sibilant 
and  sonorous  rales  may  be  heard  on  both  sides  of  the 
chest  (as  shown  in  Fig.  3).  In  the  stage  of  secretion, 
along  with  the  sibilant  and  sonorous  rales,  mucous  rales, 
large  and  small,  are  heard  on  both  sides  of  the  chest  (see 
Fig.  3).  These  rales  are  inconstant,  coming  and  going, 
and  changing  their  situation.  When  the  rales  are  intense 
and  abundant,  they  altogether  mask  the  respiratory  mur- 
mur. In  some  cases  of  slight  bronchitis  of  the  larger 
tubes,  there  are  no  distinct  rales,  but  the  respiration  has 
a  sonorous  character. 

The  Vocal  Resonance  is  normal. 


54  PHYSICAL   DIAGNOSIS. 

Capillary  Bronchitis. 

Capillary  Bronchitis,  or  bronchitis  affecting  the  ulti- 
mate, or  capillary,  bronchial  tubes. 

Inspection  and  Palpation  give  the  same  signs  as  in 
simple  bronchitis. 

Percussion  is  normal,  or  it  may  be  slightly  exag- 
gerated. 

Auscultation  shows,  if  the  disease  is  extensive,  that 
the  vesicular  murmur  is  weakened  or  suppressed.  In  its 
stead,  sub -crepitant  rales  are  heard  on  both  sides  of  the 
chest,  accompanied  by  sibilant  rales  of  a  markedly  hissing 
character. 

The  Vocal  Resonance  is  normal. 

Differential  Diagnosis  of  Bronchitis. — The  diagnosis 
of  bronchitis  of  the  larger  tubes  is  readily  made.  Some- 
times, however,  the  gravitation  of  fluid  from  the  larger 
to  the  smaller  tubes  may  give  rise  to  sub-crepitant  rales 
over  a  circumscribed  area  posteriorly. 

Capillary  bronchitis  may  be  confounded  with  pneu- 
monia, and  with  acute  or  chronic  tuberculosis.  It  is  dis- 
tinguished from  pneumonia  by  its  normal  or  exaggerated 
resonance  on  percussion,  by  the  existence  of  sub-crepitant 
rales  on  both  sides  of  the  chest,  and  by  the  absence  of 
bronchial  breathing.  The  diagnosis  of  capillary  bron- 
chitis from  tuberculosis  will  be  considered  under  the  head 
of  the  latter. 

If  the  sub-crepitant  rales  are  confined  to  the  apex  or 
base  of  one  lung,  and  there  is  resonance  on  percussion, 
the  bronchitis  is  either  of  a  tubercular  or  emphysematous 
origin. 

Dilatation  of  Bronchi.     {Bronchiectasis.) 

Bronchiectasis  is  usually  associated  with  fibrous  in- 
duration of  the  lung  or  with  emphysematous  enlarge- 


PULMONARY    EMPHYSEMA.  55 

ment,  and  is  recognized  by  the  following  physical 
signs  : 

Inspection  shows  defective  expansive  movements  of 
the  chest,  and  prolonged,  labored  expiratory  movements. 

Palpation. — Vocal  fremitus  varies,  rhonchial  fremitus 
frequently  present. 

Percussion  is  amphoric,  unless  the  accumulation  of 
thick  secretion  gives  rise  to  obstruction  of  the  tubes,  and 
consequent  local  solidification  of  the  lung  ;  in  such  cases 
there  is  temporary  dulness.  This  dulness  is  to  be  distin- 
guished from  the  dulness  of  pneumonia  by  its  tempo- 
rary character,  and  by  the  variations  in  vocal  fremitus. 
From  pneumonic  consolidation  it  is  distinguished  by  the 
presence  of  cavernous  and  amphoric  breathing. 

Auscultation. — The  results  of  auscultation  vary  ac- 
cording to  the  condition  of  the  cavity.  When  it  is  full, 
the  respiratory  sounds  are  more  or  less  deficient  over  por- 
tions of  the  chest ;  when  it  is  empty,  they  become  harsh 
and  loud.  They  are  accompanied  by  a  variety  of  rales, 
chiefly  sonorous.  But  after  profuse  expectoration,  large 
mucous  rales  or  gurgles  may  be  present.  The  sounds  in 
any  portion  of  the  lung  are  constantly  changing  in  cha- 
racter, altered  by  cough  or  a  full  inspiration. 


Pulmonary  Emphysema. 

Inspection  in  a  well-marked  example  of  this  disease 
reveals  alterations  in  the  shape  and  movements  of  the 
chest.  The  sternum  is  often  abnormally  prominent,  as 
if  from  congenital  deformity.  There  is  bulging  of  the 
infra-clavicular  and  mammary  regions,  which  gives  to 
the  upper  portion  of  the  chest  a  more  rounded  appearance 
than  in  health,  or,  as  it  is  called,  " barrel- shaped."  The 
shoulders  are  elevated  and  brought  forward  ;   there  is 


56  PHYSICAL  DIAGNOSIS. 

more  or  less  anterior  curvature  of  the  spine,  and  the 
person  appears  to  stoop.  The  lower  portion  of  the  chest 
seems  contracted,  and  the  intercostal  spaces  are  widened 
in  the  upper,  narrowed  in  the  lower  spaces.  In  some 
instances  in  which  the  general  symptoms  of  emphysema 
are  well  marked,  the  lung  is  atrophied  instead  of  being 
abnormally  dilated,  and  no  bulging  or  prominence  of  the 
chest  occurs,  either  general  or  local. 

The  movements  of  the  chest  walls  are  also  altered. 
At  the  upper  portion,  expansion  on  inspiration  is  dimin- 
ished or  entirely  wanting.  The  whole  chest  moves  ver- 
tically up  and  down  with  inspiration  and  expiration,  as 
if  it  were  passively  lifted  from  the  shoulders  and  com- 
posed of  one  solid  piece  ;  while  below,  the  chest,  instead 
of  being  dilated  with  inspiration,  is  contracted.  'The 
respiratory  efforts  are  labored,  and  the  breathing  is 
chiefly  abdominal. 

Palpation. — The  vocal  fremitus  varies  ;  it  may  fall 
below,  it  may  equal,  or  exceed,  the  average  of  health. 
The  apex  beat  of  the  heart  is  often  not  perceptible  in  the 
precordial  space  ;  sometimes  it  is  felt  much  lower  than 
its  normal  position. 

Mensuration  shows  a  marked  increase  in  the  antero- 
posterior diameter  of  the  chest. 

Percussion. — The  intensity  of  the  percussion  sound  is 
increased,  the  pitch  is  lowered,  the  pulmonary  quality  of 
the  sound  is  greatly  diminished,  and  it  becomes  what  has 
already  been  described  as  vesiculo -tympanitic.  The  per- 
cussion note  is  not  materially  affected  either  by  forced 
inspiration  or  forced  expiration. 

Auscultation. — As  a  rule,  the  inspiratory  sound  is 
either  short  and  feeble,  or  actually  suppressed,  and  the 
expiratory  sound  is  greatly  prolonged  :  the  ratio  of  the 
two  sounds  being  as  1  :  1   instead  of  4:1.     The  pitch  of 


SPASMODIC    ASTHMA.  57 

both  inspiratory  and  expiratory  sounds  is  lower  than  in 
health. 

In  some  extreme  cases  of  emphysema,  the  respiratory 
sounds  are  of  equal  length,  greatly  exaggerated  in  inten- 
sity, and  of  a  harsh,  sibilant  quality,  the  harsh  quality, 
undoubtedly,  being  due  to  diminution  in  the  calibre  of 
the  minute  bronchial  tubes. 

Vocal  Resonance  varies  greatly  ;  sometimes  it  is  di- 
minished or  altogether  absent  ;  at  others  its  intensity  is 
greatly  increased.  The  heart  sounds  are  feeble,  and  in 
rare  instances  the  organ  is  pushed  downward  toward 
the  epigastrium. 

Differential  Diagnosis. — The  only  disease  with  which 
emphysema  is  liable  to  be  confounded  is  pneumo- 
thorax. The  distinction,  however,  is  not  very  difficult, 
for  in  emphysema  the  percussion  sound,  although  tym- 
panitic, still  retains  a  pulmonary  quality,  and  there  is 
a  vesicular  element  to  the  respiratory  sound  ;  while  in 
pneumothorax  the  percussion  sound  has  a  complete 
tympanitic  character,  and  the  respiration,  if  audible,  is 
amphoric.  Besides,  pneumothorax  affects  only  one 
side,  emphysema  both. 

Spasmodic  Asthma  {during  the  Paroxysm). 

Inspection  shows  labored  respiration. 

Palpation,  vocal  fremitus  normal. 

Percussion  is  normal  or  exaggerated. 

Auscultation. — The  rhythm  of  the  respiratory  mur- 
mur is  jerking  and  irregular ;  sometimes  it  is  exagge- 
rated, at  others  it  is  suppressed.  Sibilant  and  sonorous 
rales,  of  a  high-pitched,  hissing  and  wheezing  charac- 
ter, are  diffused  over  the  whole  chest,  often  loud  enough 
to  be  heard  at  a  distance. 

Voccd  Resonance  is  normal. 


58 


PHY&ICAL   DIAGNOSIS. 

Acute  Lobar  Pneum.onia. 


The  physical  signs  of  pneumonia  vary  with  its  differ- 
ent stages. 

First  Stage,  or  Stage  of  Engorgement.  Inspec- 
tion.— The  movements  of  the  affected  side  are  more  or 
less  restrained. 


1st  Stage. 


I  Slight  dulness. 
(  Crepitant  rale. 


Complete  dulness.    .    .    , 
Bronchial  respiration.     , 

!  ~  i  Bronchophony 

Increased  vocal  fremitus, 


(  Diminished  dulness.    .    . 

|  Sub-crepitantrale.      .    . 

3d  Stage.  "\  Broncho-vesic  respiration 

I  Increased  vocal  resonance 

^  Increased  vocal  fremitus. 


Fig.  6.— Diagram  illustrative  of  the  Physical  Signs  of  the  three  stages  of  Pneumonia. 

Palpation. — Vocal  fremitus  is  slightly  increased  on  the 
affected  side. 

Percussion. — There  is  slight  dulness  over  so  much  of 
lung  tissue  as  is  involved  in  the  pneumonic  inflamma- 
tion, the  degree  of  dulness  depending  upon  the  amount 
of  exudation  into  the  lung  substance. 

Auscultation. — In  the  early  period  of  engorgement, 
before  the  exudation  takes  place,  the  respiratory  mur- 
mur is  diminished  in  intensity  in  the  affected  part,  and 
exaggerated  in  other  portions  of  the  affected  lung,  as 


ACUTE   LOBAR   PNEUMONIA.  50 

well  as  in  the  healthy  lung.  As  soon  as  exudation  takes 
place  into  the  air  cells,  or  on  the  pleural  surface,  the 
crepitant  rale  may  be  heard  toward  the  end  of  in- 
spiration. It  is  the  characteristic  sign  of  the  first  stage 
of  pneumonia.  In  some  cases,  especially  when  pneumo- 
nia is  developed  in  connection  with  acute  articular  rheu- 
matism, crepitation  never  occurs. 

Second  Stage,  or  Red  Hepatization.  Inspection. — 
The  expansive  movements  are  diminished  on  the  af- 
fected side,  and  increased  on  the  healthy. 

Palpation. — As  a  rule,  vocal  fremitus  is  increased; 
occasionally  it  is  diminished. 

Percussion. — There  is  marked  dulness  over  a  space 
corresponding  to  the  consolidated  lung  tissue,  and  in- 
creased resonance  over  the  healthy  portion  of  the  af- 
fected lung."  The  relation  of  the  resonance  and  dulness 
is  not  affected  by  a  change  in  the  position  of  the  patient. 
Absolute  dulness  or  flatness  on  firm  percussion  very 
rarely  exists. 

Auscultation. — As  the  air  cells  become  completely 
filled  with  exudation  the  crepitant  rales. cease,  and  bron- 
chial respiration  is  heard  over  the  solidified  lung  tissue. 
The  more  complete  the  consolidation  the  more  intense 
and  tubular  is  the  bronchial  respiration. 

Vocal  Resonance. — There  is  marked  bronchophony 
over  all  that  portion  of  lung  which  is  the  seat  of  pneu- 
monic consolidation.  The  heart  sounds  are  transmitted 
to  the  surface  with  unnatural  intensity.  The  character- 
istic physical  signs  of  this  stage  are  dulness  on  percus- 
sion, bronchial  breathing,  and  bronchophony. 

Third  Stage,  or  Gray  Hepatization. — The  physical 
signs  in  the  early  part  of  this  stage  are  the  same  as  those 
of  the  second  stage.  They  are  simply  the  signs  of  con- 
solidation.    In  the  latter  or  resolving  part  of  this  stage, 


60  PHYSICAL   DIAGNOSIS. 

percussion  shows  progressive  diminution  in  dulness.  It 
is  often,  however,  a  long  time  before  normal  pulmo- 
nary resonance  is  perfectly  restored. 

Auscultation. — The  bronchial  respiration  of  the  sec- 
ond stage  gradually  gives  place  to  rude  (or  broncho- 
vesicular)  respiration,  and  this  in  turn  approximates 
to,  and  at  length  ends  in,  normal  vesicular  breathing. 
As  the  bronchial  respiration  diminishes,  the  crepitant 
and  sub-crepitant  rales,  or  "  rale  redux,"  are  developed, 
and  remain  audible  until  resolution  is  complete.  Bron- 
chophony gives  place  to  exaggerated  vocal  resonance, 
and  that  in  turn  to  normal  vocal  resonance.  The  phy- 
sical signs  of  chronic  pneumonia  will  be  considered  in 
connection  with  tuberculosis. 

Lobular  Pneumonia. 

The  areas  of  consolidation  vary  from  the  size  of  a  pea  to 
that  of  a  hazelnut.  They  are  usually  scattered  through- 
out both  lungs,  but  in  some  instances  isolated  nodules 
may  become  confluent  and  the  greater  part  of  a  lobe  be 
consolidated. 

Lobular  pneumonia  is  associated,  as  a  rule,  with  a 
catarrh  of  the  smaller  tubes,  and  occurs  most  frequently 
in  children  and  old  people. 

Inspection. — In  the  severe  lobular  pneumonia  of  chil- 
dren, the  respirations  are  hurried,  shallow,  and  imper- 
fect. There  is  only  slight  expansion  of  the  chest,  or  in 
some  cases  there  may  even  be  retraction  of  its  lower 
portion  during  a  full  inspiration.  In  adults  inspection 
reveals  only  an  increased  frequency  of  the  respiratory 
acts. 

Palpation  gives  negative  results  unless  the  consoli- 
dated areas  are  of  considerable  size  and  situated  near 
the  surface  of  the  lung. 


PULMONARY    CEDEMA.  61 

(  Percussion. — Dulness  is  present  over  circumscribed 
areas.  It  may  be  slight  or  complete,  depending  upon 
the  extent  and  location  of  the  consolidation. 

Dulness  in  children  can  be  elicited  only  by  gentle  per- 
cussion. 

On  Auscultation  small  mucous  rales^,  resembling  the 
sub-crepitant,  having  a  fine  crackling  and  metallic  cha- 
racter, are  heard  over  the  areas  of  dulness.  They  are 
audible  both  with  inspiration  and  expiration.  The  breath- 
ing is  at  first  feeble,  but  gradually  it  becomes  broncho- 
vesicular,  or  even  bronchial.  The  vocal  resonance  is  in- 
creased :  it  may  be  bronchophonies 

Differential  Diagnosis. — Lobular  pneumonia  is  most 
likely  to  be  mistaken  for  capillary  bronchitis.  The  dul- 
ness on  percussion,  the  localization  of  the  rales  to  cir- 
cumscribed areas,  and  the  broncho- vesicular  or  bronchial 
breathing,  will  readily  distinguish  it. 

Pulmonary  CEdema. 

In  oedema  of  the  lungs  inspection  and  palpation  fur- 
nish no  positive  information. 

Percussion. — There  is  more  or  less  dulness  on  percus- 
sion (never,  however,  complete),  diffused  over  the  poste- 
rior surface  of  the  chest  on  both  sides,  and  marked  at  the 
most  dependent  portion  of  the  lungs. 

Auscultation.  —  The  respiratory  murmur  is  feeble, 
sometimes  almost  entirely  absent.  With  the  inspiratory 
sound,  crackling  rales  are  heard  over  the  seat  of  the 
oedema ;  the  crackling  resembles  somewhat  the  crepi- 
tant rale  -of  pneumonia,  but  is  distinguished  from  it  by 
its  liquid  character. 

Differential  Diagnosis. — Pulmonary  oedema  may  be 
confounded  with  the  first  stage  of  pneumonia,  with  hy- 
drothorax,  and  with  capillary  bronchitis.     It  is  distin- 


02  PHYSICAL   DIAGNOSIS. 

guished  from  pneumonia,  as  we  mentioned  above,  by  the 
liquid  character  of  the  crackling  rales,  and  by  its  occur- 
ring on  both  sides,  at  the  most  dependent  portions  of  the 
lungs,  pneumonia  usually  being  confined  to  one  lung ; 
from  hydrothorax,  by  the  presence  of  rales,  and  by  the 
level  of  the  dulness  not  being  changed  by  a  change  in 
the  position  of  the  patient ;  from  capillary  bronchitis, 
by  the  slight  dulness  on  percussion  which  attends  it, 
and  by  the  absence  of  the  rales  in  the  larger  bronchial 
tubes. 

Pulmonary  Gangrene. 

The  physical  signs  of  pulmonary  gangrene  are  often 
obscure  and  never  distinctive.  They  are  those  of  local 
consolidation  followed  by  the  evidences  of  the  breaking 
up  of  lung  tissue  and  the  formation  of  cavities  in  the 
lung  substance.  There  are  no  special  signs  indicating 
the  nature  of  the  disorganizing  process  ;  sometimes  it  is 
preceded  by  the  signs  of  pneumonia  ;  generally  it  is  ac- 
companied by  the  signs  of  bronchitis,  and  late  in  the 
disease  there  are  physical  evidences  of  the  formation 
of  cavities  in  the  lung  substance. 

Pulmonary  Haemorrhage. 

The  physical  signs  of  a  slight  haemorrhage  from  the 
lungs  are  very  obscure.  No  information  as  to  the  seat 
or  amount  of  the  haemorrhage  is  furnished  by  inspection, 
palpation,  or  percussion.  Auscultation  may,  however, 
indicate  the  spot  at  which  the  haemorrhage  occurs,  by  the 
presence  of  moist  rales.  If  the  haemorrhage  is  profuse 
and  accompanied  by  pulmonary  apoplexy,  abundant 
moist  rales  will  be  heard  at  the  seat  of  the  effusions,  and 
they  remain  audible  until  coagulation  takes  place  or  the 
effusion  is  removed.    When  pulmonary  apoplexy  occurs, 


PULMONARY   CANCER.  63 

it  is  usually  found  in  the  lower  and  posterior  portions 
of  the  lungs.  If  the  nodules  are  few  and  small,  there 
will  be  no  positive  physical  evidences  of  their  situation. 
When  the  nodules  are  large  and  lie  superficially,  percus- 
sion will  give  more  or  less  dulness  over  a  limited  space 
corresponding  to  the  extent  of  the  haemorrhage,  and  on 
auscultation  there  will  be  a  diminution  or  absence  of  the 
respiratory  murmur.  When  the  extravasation  is  situ- 
ated near  a  large-sized  bronchial  tube,  bronchial  breath- 
ing and  increased  vocal  resonance  are  heard,  and  there 
is  also  increase  in  the  vocal  fremitus. 

Pulmonary  Cancer. 

Cancer  of  the  lungs  may  be  primary  or  secondary.  In 
the  primary  form,  only  one  lung  is  affected,  and  the 
growth  occurs  as  a  single  mass.  In  the  secondary,  both 
lungs  are  involved,  and  the  new  growth  usually  takes  the 
form  of  disseminated  nodules  of  varying  size.  The  latter 
variety  cannot  be  distinguished  by  physical  examination 
from  simple  bronchial  catarrh,  but  pulmonary  symp- 
toms occurring  a  year  or  so  after  the  removal  of  a  can- 
cer are  very  suggestive. 

Where  the  growth  is  single  and  large- 

Inspection  shows  obliteration  or  bulging  of  the  inter- 
costal spaces.  This  may,  however,  be  due  to  a  compli- 
cating liquid  effusion.  Occasionally  there  is  retraction 
of  the  chest  wall.  The  movements  of  respiration  are 
impaired. 

Palpation  gives  diminished  or  absent  vocal  fremitus. 

Percussion  gives  comparative  or  absolute  dulness,  ac- 
cording as  whether  the  mass  is  deep-seated  or  superficial. 

Auscultation. — The  respiratory  and  voice  sounds  are 
usually  absent  over  the  affected  portion  of  the  lung. 
But  if  a  large  open  bronchus  passes  through  the  mass, 


64  PHYSICAL   DIAGNOSIS. 

bronchial  breathing  and  voice  will  be  heard.     The  signs 
on  the  healthy  side  may  be  exaggerated. 

Differential  Diagnosis. — The  only  disease  with  which 
pulmonary  cancer  is  likely  to  be  confounded  is  pleurisy 
with  effusion.  In  cancer,  however,  the  line  of  dulness 
does  not  change  when  the  position  of  the  patient  is 
altered;  the  dulness  does  not  begin  at  the  lowest  portion 
of  the  thorax  and  extend  upward ;  and  there  may  be 
one  or  more  points  where  slight  resonance  on  percus- 
sion is  obtained.  In  cancer,  the  dulness  is  most  marked 
in  front,  whereas  in  pleurisy  it  is  greatest  behind.  Pain 
is  present  if  the  pleura  is  involved,  and  pressure  symp- 
toms are  sometimes  seen. 

Pulmonary  Collapse. 
Complete  collapse  of  large  portions  of  lung  may  be 
produced  either  by  bronchitis  or  compression.  There  are 
no  physical  signs  to  indicate  its  occurrence,  unless  the 
collapsed  lung  is  in  contact  with  the  chest  wall,  and  then 
the  signs  are  not  very  distinctive.  Usually  there  is  over 
the  space  where  it  occurs  some  dulness  on  percussion, 
localized  bronchial  breathing,  and  increased  vocal  fremi- 
tus. When  there  is  collapse  of  only  a  few  vesicles,  a 
deep  inspiration  may  bring  out  a  crepitant  rale,  audible 
during  a  few  respirations,  and  then  heard  no  more. 
Congenital  atelectasis  gives  rise  to  no  physical  signs, 
unless  there  is  marked  inspiratory  dyspnoea  and  retrac- 
tion of  chest  walls. 

Pulmonary  Congestion. 

There  are  no  recognizable  physical  signs  of  simple 
pulmonary  congestion,  unless  it  is  associated  with  pul- 
monary oedema  or  bronchial  haemorrhage. 

It  may  be  suspected  when  extreme  dyspnoea  comes  on 
suddenly  after  violent  physical  exertion,  or  daring  the 


PULMONARY   CONGESTION.  65 

inhalation  of  highly  rarefied  air  met  with  in  high  alti- 
tudes, especially  if,  with  the  dyspnoea,  you  have  the 
physical  signs  of  pulmonary  oedema,  and  a  watery  blood- 
stained expectoration. 

Some  auscultators  have  regarded  intensification  of  the 
second  sound  of  the  heart  over  the  pulmonary  arteries  as 
a  diagnostic  physical  sign  of  pulmonary  congestion  ;  but 
tnis  evidence  is  fallacious,  for  greater  intensity  of  the 
second  pulmonary  sound  may  be  merely  relative,  and  due 
to  weakness  of  the  aortic  sound. 

5 


LESSOR    VIII. 

A    SYNOPSIS    OF    PHYSICAL     SIGNS     IN    THE     DIAGNOSIS    OF 
PULMONARY   DISEASES — CONTINUED. 

Pleurisy. 

There  are  three  recognized  varieties  of  pleurisy,  Acute, 
Sub-Acute,  and  Chronic  or  Empyema.  In  acute,  there  is 
but  little  liquid  effusion ;  in  sub-acute,  the  liquid  effusion 
is  abundant,  often  completely  filling  the  pleural  cavity; 
in  empyema,  the  effusion  is  purulent,  comparatively 
small  in  quantity,  and  usually  circumscribed.  I  shall 
consider  the  physical  signs  of  the  three  varieties  sepa- 
rately. 

Acute  Pleurisy 

may  be  divided  into  four  stages — a  dry  stage,  a  plastic 
stage,  a  stage  of  liquid  effusion,  and  a  stage  of  absorp- 
tion. 

Dry  Stage. — Inspection  shows  a  diminution  in  the 
respiratory  movements,  especially  in  expansion  of  the 
affected  side.  They  are  also  quick,  catching,  and  irreg- 
ular. Palpation,  mensuration,  and  percussion  yield  only 
negative  results. 

Auscultation.  —  The  respiratory  murmur  is  feeble, 
jerking,  and  interrupted  ;  occasionally  a  grazing  friction 
sound  is  heard  over  the  seat  of  the  pleuritic  inflamma- 
tion. 

Stage  of  Plastic  Exudation.  Inspection. — The  res- 
piratory movements  of  the  affected  side  are  still  more 


ACUTE    PLEURISY.  67 

diminished,  while  those  of  the  healthy  side  are  in- 
creased. 

Palpation. — Vocal  fremitus  is  diminished. 

Percussion. — There  is  more  or  less  dulness  over  the 
seat  of  the  plastic  exudation.  If  the  dulness  is  marked, 
the  plastic  matter  is  abundant.  The  dulness  will  be  less 
at  the  end  of  a  full  expiration. 

Auscultation. — The  respiratory  murmur  over  the  seat 
of  the  pleuritic  inflammation  is  feeble  or  entirely  absent, 
and  a  rubbing  or  crepitating  friction  sound  is  heard, 
most  distinctly  at  the  end  of  the  inspiratory  act,  as 
shown  in  Fig.  5,  p.  45. 

Vocal  Resonance.  —  The  intensity  of  the  vocal  re- 
sonance is  diminished. 

Stage  of  Liquid  Effusion.  Inspection. — In  acute 
pleurisy  the  quantity  of  liquid  effusion  is  generally 
small,  as  shown  in  Fig.  5  ;  consequently  there  is  no 
dilatation  of  the  affected  side.  When  it  appears,  the 
jerking  movements  of  the  dry  and  plastic  stages  cease, 
and  there  is  no  visible  motion  at  the  seat  of  the  liquid 
accumulation. 

Palpation. — Vocal  fremitus  is  absolutely  suppressed 
over  the  effused  liquid. 

Percussion. — When  the  patient  is  sitting  or  standing, 
there  is  flatness  on  percussion,  from  the  base  of  the  lung 
on  the  affected  side  to  the  level  of  the  liquid,  as  shown  in 
Fig.  5.  The  line  of  the  flatness  may  be  changed  by 
changing  the  position  of  the  patient. 

Auscultation.  —  The  respiratory  sounds  below  the 
level  of  the  liquid  are  suppressed ;  above,  they  are  ex- 
aggerated. The  friction  sounds  disappear  where  the 
effusion  prevents  the  pleural  surfaces  from  coming  in 
contact  with  each  other  ;  but  above  the  liouid  they  con- 
tinue to  be  heard,  as  shown  in  Fig.  5. 


68  PHYSICAL   DIAGNOSIS. 

Vocal  Resonance. — Below  the  level  of  the  liquid  the 
vocal  sounds  are  feeble  or  entirely  abolished. 

Stage  op  Absorption. — This  stage  is  marked  by  the 
gradual  return  of  pulmonary  resonance  on  percussion, 
and  of  the  normal  vocal  and  respiratory  sounds.  As  the 
effusion  disappears  creaking  friction  sounds  are  audible 
for  a  brief  period. 

Sub-Acute  Pleurisy. 
In  this  variety  of  pleurisy  the  pleural  cavity  may  be 
partly  or  completely  filled  with  liquid .    In  addition,  there 


Absence  of  respiratory  sounds 
"         "  vocal  sounds. 
"  ll  vocal  fremitus. 

Flatness  on  percussion 


Fie.  7.— Diagram  showing  the  Pleural  Cavity  completely  filled  with  Liquid,  the  Linux 
being  compressed. 

is  a  moderate  amount  of  plastic  exudation,  which  thick- 
ens and  roughens  the  pleural  surfaces.  When  the  cavity 
is  partly  filled,  the  presence  and  amount  of  the  effusion 
are  determined  by  the  same  physical  signs  that  mark  the 
effusive  stage  of  acute  pleurisy.  When  the  pleural 
cavity  is  distended  by  accumulation  of  the  liquid,  the 
lung  is  compressed  against  the  spinal  column,  and  impor- 
tant changes  in  the  physical  signs  occur. 


SUB-ACUTE    PLEURISY.  G9 

Inspection  shows  perfect  immobility  of  the  chest  walls, 
with  general  enlargement  of  the  affected  side.  The  inter- 
costal spaces  bulge  more  or  less,  and  the  cardiac  impulse 
is  visible  in  an  abnormal  position. 

Mensuration  shows  an  enlargement  of  the  affected 
side,  both  in  its  circumference  and  in  its  antero-posterior 
diameter ;  the  enlargement  is  greatest  over  the  false 
ribs,  the  affected  side  often  measuring  one  or  two  inches 
more  than  the  healthy. 

Palpation  shows  the  vocal  fremitus  to  be  wanting. 

Percussion. — There  is  general  flatness  on  percussion 
over  the  affected  side,  the  flatness  extending  beyond  the 
natural  limits  of  the  lung.  Under  the  clavicle  the  per- 
cussion sound  sometimes  has  a  tympanitic  quality. 

Auscultation. — There  is  entire  absence  of  all  respira- 
tory and  vocal  sounds  over  the  affected  side,  except  at 
the  upper  portion  of  the  compressed  lung ;  here  bron- 
chial respiration  and  bronchophony  are  heard.  Some- 
times these  sounds  are  diffused  over  the  affected  side. 
The  respiratory  sound  over  the  healthy  lung  is  exag- 
gerated. 

In  the  Stage  of  Absorption,  inspection  informs  us 
that  the  enlargement  of  the  affected  side  is  disappear- 
ing, that  the  intercostal  spaces  are  regaining  their  normal 
condition,  and  that  the  respiratory  movements  of  the 
chest  walls  are  returning,  although  restricted. 

Palpation  shows  a  gradual  return  of  vocal  fremitus. 

Mensuration  shows  a  gradual  diminution  in  the  mea- 
surement of  the  affected  side,  until  it  becomes  even  less 
than  the  opposite  side. 

Percussion. — The  percussion  sound  gradually  recovers 
its  normal  resonance,  first  at  the  upper  and  then  at  the 
lower  portion  of  the  pleural  cavity;  sometimes  in  the 
inferior  portion   it   never  regains  its  normal  resonance, 


70  PHYSICAL  DIAGNOSIS. 

owing  to  the  great  accumulation  of  solid,  plastic  mate- 
rial, or  condensation  of  lung  tissue. 

Auscultation.  —  The  respiratory  sounds  are  again 
heard,  at  first  weak  and  distant ;  gradually  they  become 
more  distinct,  and  sometimes  harsh  in  character.  As 
the  absorption  of  the  liquid  takes  place,  and  the  two 
surfaces  of  the  pleura  again  come  in  contact,  a  friction 
sound,  of  a  creaking,  crepitating  character,  appears,  and 
remains  audible  for  a  variable  period.  The  vocal  reso- 
nance is  at  first  bronchophonic,  then  exaggerated,  and 
ultimately  becomes  normal.  The  heart,  with  the  ad- 
jacent abdominal  viscera,  returns  to  its  normal  position, 
sometimes  with  singular  promptness.  If,  as  sometimes 
happens,  the  lung  remains  permanently  impervious  to 
air,  then  there  is  a  permanent  loss  of  motion  on  the 
affected  side,  and  there  is  no  return  of  the  respiratory  or 
vocal  sounds,  while  dulness  on  percussion  is  persistent. 
A  portion  of  the  lung  (usually  the  upper)  sometimes 
becomes  partially  pervious  to  air ;  when  this  is  the 
case,  the  percussion  sound  over  it  will  have  a  tympa- 
nitic quality,  the  vocal  resonance  will  be  exaggerated, 
and  the  respiratory  sound  coarse  and  blowing. 

Empyema. — The  physical  signs  of  empyema  are  the 
same  as  those  of  sub-acute  pleurisy,  when  the  pleural 
cavity  is  partially  filled  with  liquid.  In  the  majority  of 
the  cases  of  empyema  that  have  come  under  my  obser- 
vation, a  change  in  the  position  of  the  patient  has  not 
caused  a  change  in  the  level  of  the  liquid,  owing  prob- 
ably to  the  firm  adhesion  that  takes  place  above  it  be- 
tween the  pleura  pulmonalis  and  pleura  costalis.  Ex- 
cessively abundant  empyematous  effusions  sometimes 
pulsate  rhythmically  with  the  heart — the  "pulsating 
empyemata. " 

Differential   Diagnosis. — The  diagnosis   of  pleurisy, 


SUB-ACUTE   PLEURISY.  71 

in  the  majority  of  cases,  is  easily  made  ;  yet  in  all  its 
different  varieties  there  is  some  danger  of  confounding 
it  with  other  diseases. 

In  the  dry  stage  of  acute  pleurisy  it  may  be  con- 
founded with  pleurodynia  and  intercostal  neuralgia.  Tt 
is  distinguished  from  them  by  the  presence  of  the  graz- 
ing friction  sound,  by  the  deep-seated  character  of  the 
pain,  and  by  the  absence  of  tenderness  on  pressure  over 
the  seat  of  pain.  It  is  further  differentiated  from  inter- 
costal neuralgia  by  not  having  the  three  points  of  ten- 
derness, viz. :  at  the  exit  of  the  nerve  from  the  spinal 
canal,  over  the  greatest  curvature  of  the  rib,  and  in  front. 

The  plastic  stage  of  pleurisy  on  the  left  side  may 
be  confounded  occasionally  with  the  plastic  stage  of 
pericarditis.  It  is  readily  distinguished  from  it  by  the 
cessation  of  the  friction  sound  during  a  temporary  sus- 
pension of  the  respiratory  movements. 

The  effusive  stage  may  be  confounded  with  con- 
solidation of  the  lung  from  pneumonia  and  tubercular 
infiltration,  with  an  enlarged  liver  or  spleen  extending 
upward,  and  with  cancerous  deposits  in  the  lungs.  It 
is  distinguished  from  pneumonia  and  tubercular  consoli- 
dation by  the  bulging  of  the  affected  side,  by  the  ab- 
sence of  vocal  fremitus,  by  the  flatness  of  the  percussion 
sound,  by  the  change  in  the  level  of  the  liquid  on  change 
in  the  position  of  the  patient,  and  by  the  absence  of  all 
vocal  and  respiratory  sounds.  The  blowing  respiration 
that  is  sometimes  heard  over  a  pleural  cavity  filled  with 
liquid  differs  from  the  true  tubular  or  bronchial  breath- 
ing of  pulmonary  consolidation  in  being  more  diffused 
and  deep-seated,  and  not  accompanied  by  any  moist 
sounds.  In  tubercular  consolidation,  the  progress  of  the 
physical  signs  is  usually  from  above  downward  ;  in  ef- 
fusion,   they   advance    from    below   upward.     Besides, 


72  PHYSICAL   DIAGNOSIS. 

pulmonary  tuberculosis  of  an  entire  lung  does  not  exist 
without  involving  the  opposite  lung,  while  any  amount 
of  pleuritic  effusion  may  exist  on  one  side  while  the 
other  remains  unaffected. 

The  physical  signs  of  the  stage  of  absorption  will 
rarely  be  confounded  with  any  other  disease.  Hyper- 
trophy of  the  liver,  enlarging  upward,  is  distinguished 
from  effusion  into  the  right  pleural  cavity  by  the  exist- 
ence of  pulmonary  percussion  and  audible  respiratory 
murmur  at  the  posterior  part  of  the  chest.  Deep  in- 
spiration also  increases  the  area  of  the  normal  percus- 
sion and  normal  respiratory  sound  at  the  inferior  por- 
tion of  the  pleural  cavity  ;  it  exerts  no  such  influence 
when  the  loss  of  resonance  and  respiratory  murmur  de- 
pends upon  pleuritic  effusion. 

Enlargement  of  the  spleen  affects  but  slightly  the  vo- 
cal or  respiratory  sounds  at  the  inferior  portion  of  the 
left  pleural  cavity.  It  causes  no  protrusion  of  the  inter- 
costal spaces,  and  does  not,  like  pleuritic  effusion,  push 
the  heart  to  the  right,  but  raises  it  upward. 

Pneumothorax. — Inspection  shows  distention  of  the 
affected  side,  widening  and  bulging  of  the  intercostal 
spaces,  and  immobility  of  the  chest  walls,  contrasting 
forcibly  with  the  costal  movements  of  the  healthy  side. 

Palpation.  —  Vocal  fremitus  is  diminished,  or  alto- 
gether wanting.  Mensuration  shows  the  affected  side 
to  be  markedly  increased  in  size. 

Percussion  elicits  a  tympanitic  resonance,  of  an  am- 
phoric or  metallic  quality,  over  the  whole  of  the  affected 
side.  When  the  dilatation  of  the  chest  is  excessive,  the 
adjacent  viscera  are  more  or  less  displaced.  The  tym- 
panitic percussion  sound  assumes  a  muffled  character, 
and  extends  considerably  beyond  the  normal  limits  of 
the  pleura. 


PNEUMOTHORAX. 


73 


Auscultation  varies  according  to  the  amount  of  air 
contained,  in  the  pleural  cavity.  If  the  cavity  is  dis- 
tended with  air,  so  that  the  lung  is  completely  com- 
pressed, the  vocal  and  respiratory  sounds  are  altogether 
absent,  and  the  heart  sounds  are  feebly  transmitted 
through  the  distended  pleura ;  if  the  quantity  of  air  is 
small,  the  respiratory  sounds  are  weak  and  distant,  and 
the  vocal  sounds  indistinct. 

Hydro-pneumothorax  usually  results  from  the  open- 


Tympanitic  resonance. 
Amphoric  respiration. 
Metnll  c  tinkling.  .  . 
Succussion  sound.  .  . 
Absent  vocal  fremitus. 

Flatness 

Absent  voice 

Absent  respiration.  . 
Displaced  viscera.  .    . 


Fig.  8.— Diagram  illustrative  of  the  Physical  Signs  of  Hydro-pneumothorax. 


ing  of  a  bronchus  into  the  pleural  cavity.  The  physical 
signs  of  this  condition  are  a  combination  of  those  of 
pleuritic  effusion  and  pneumothorax.  As  in  pneumo- 
thorax, inspection  reveals  dilatation  of  the  affected  side, 
widening  and  bulging  of  the  intercostal  spaces,  immo- 
bility of  the  chest  walls,  and  displacement  of  the  heart 
and  adjacent  viscera.  There  is  entire  absence  of  vocal 
fremitus. 

Percussion. — When  the  patient  is  sitting  or  standing, 
there  will  be  tympanitic  resonance  on  percussion  from 


74  PHYSICAL   DIAGNOSIS. 

the  summit  of  the  affected  side  to  the  level  of  the  liquid, 
and  flatness  below  ;  the  relation  of  the  flatness  and  tym- 
panitic resonance  changing  with  the  change  in  the  posi- 
tion of  the  patient. 

Auscultation. — Below  the  level  of  the  liquid  there  is 
entire  absence  of  all  the  respiratory  and  vocal  sounds  ; 
above  its  level  there  is  usually  amphoric  respiration  and 
metallic  tinkling. 

The  characteristic  physical  sign  of  this  disease  is  the 
succussion  sound,  which  is  a  metallic,  splashing  sound, 
produced  by  abruptly  shaking  the  chest  while  the  ear  is 
resting  on  its  surface. 

The  respiration  on  the  healthy  side  is  exaggerated. 
When  pneumothorax  is  secondary  to  advanced  tuber- 
culosis, the  lung  often  remains  adherent  to  the  chest 
wall,  and  great  distention  of  the  affected  side  is  pre- 
vented. Complete  catarrhal  obstructions  in  the  main 
bronchi  sometimes  give  signs  similar  to  those  of  pneu- 
mothorax. 

Pulmonary  Tuberculosis. 

Tuberculosis  of  the  lungs  may  be  divided  into  Acute 
and  Chronic.  The  Acute  occurs  in  two  forms,  Acute 
Miliary  Tuberculosis  and  Acute  Tubercular  Pneumonia. 

ACUTE  MILIARY  TUBERCULOSIS. 

Acute  Miliary  Tuberculosis,  in  which  there  is  a  dis- 
semination of  miliary  tubercles  throughout  the  lungs, 
cannot  be  differentiated,  by  the  physical  signs,  from  a 
catarrh  of  the  smaller  bronchial  tubes.  The  diagnosis 
rests  upon  an  examination  of  the  sputum  (see  page  207), 
but  is  only  of  value  when  a  positive  result  is  obtained. ! 

1  Von  Jaksch  states  that  the  bacilli  are  never  present  in  this  form. 
of  the  disease. 


CHRONIC    PULMONARY    TUBERCULOSIS.  75 

ACUTE   TUBERCULAR   PNEUMONIA. 

Ill  this  form  of  the  disease,  lobules  or  an  entire  lobe 
may  rapidly  become  consolidated.  The  physical  signs 
are  the  same  as  those  of  lobular  or  lobar  pneumonia  (see 
pages  5S  and  60).  Here  again  the  microscope  is  neces- 
sary to  complete  the  diagnosis. 

CHRONIC  PULMONARY  TUBERCULOSIS.      (Chronic  PMMsis.) 

Early  Stage. — The  lesion  is  usually  situated  about 
an  inch  from  the  apex  of  the  lung,  and  nearer  the  pos- 
terior than  the  anterior  surface  ;  consequently  the  physi 
cal  signs  will  be  best  marked  behind. 

Inspection  affords  little  information  unless  the  con- 
solidation is  extensive  and  confined  to  one  apex,  where 
expansion  in  the  infra-  and  supra-clavicular  regions  of 
the  affected  side  will  be  diminished,  and  there  will 
be  some  flattening  of  the  upper  part  of  the  chest 
wall. 

Palpation. — By  palpation  you  will  often  detect  de- 
ficient expansion  in  the  infra-clavicular  region  of  the 
affected  side  when  it  cannot  be  detected  by  inspection. 
There  is  also  slight  increase  in  the  vocal  fremitus  ;  this 
increase,  however,  is  less  significant  when  it  occurs  on 
the  right  side  than  on  the  left. 

Percussion. — The  difference  in  the  percussion  note  in 
the  infra-clavicular  region  on  the  two  sides,  rather  than 
the  quality  of  the  sound,  is  important.  But  it  must  be 
remembered  that  normally  there  exists  a  discrepancy  in 
the  two  sides.  On  the  right  the  pulmonary  resonance  is 
Less  marked  and  the  pitch  of  the  percussion  sound  is 
aigher. 

If  the  consolidation  is  slight  and  superficial,  the  pitch 
>f  the  percussion  sound  on  the   affected   side   will  be 


70  PHYSICAL   DIAGNOSIS. 

slightly  raised.  But  if  healthy  or  emphysematous  lung 
tissue  intervene  between  the  consolidated  lung  and  the 
chest  walls,  the  percussion  sound  may  be  normal,  or  ex- 
tra resonant,  over  the  affected  portion.  To  detect  pul- 
monary consolidation  under  such  circumstances,  the  per- 
cussion blow  must  be  forcible,  and  directed  from,  not 
toward,  the  trachea.  If  doubts  exist,  the  percussion 
should  be  performed  at  the  end  of  a  full  inspiration  and 
at  the  end  of  a  full  expiration.  As  consolidation  in- 
creases, the  pitch  of  the  percussion  sound  rises  and  its 
clearness  diminishes,  until,  in  some  cases,  absolute  dul- 
ness  is  reached. 

Auscultation. — The  respiratory  sound  in  the  infra  - 
and  supra-clavicular  regions  of  the  affected  side  is  weak 
or  suppressed  at  some  points,  and  exaggerated  at  others. 
It  may  be  jerking,  wavy,  or  "cogged-wheel"  in  its 
rhythm,  and  rude  or  bronchial  in  its  quality.  The  in- 
spiratory sound  loses  its  soft,  breezy  character,  and  be- 
comes higher  pitched  and  tubular  ;  while  the  expiratory 
becomes  higher  pitched  than  the  inspiratory,  and  is  pro- 
longed. Prolonged  expiration,  however,  if  unattended 
with  any  alteration  in  quality,  is  insignificant.  The 
value  of  these  states  of  the  respiration  corresponds  to 
their  position.  If  they  exist  above  and  are  imperceptible 
below  the  second  interspace,  they  are  seriously  signifi- 
cant. Localized  mucous  or  sub-crepitant  rales,  heard 
over  a  limited  space  at  the  apex  of  the  lung,  are  always 
important  signs  of  tuberculosis,  and  indicate  the  de- 
velopment of  broncho-  or  catarrhal  pneumonia.  They 
are  often  present  before  any  appreciable  change  in  the 
respiratory  murmur  occurs.  At  first  they  are  more  or 
less  obscure  in  proportion  to  the  weakening  of  the  res- 
piration ;  gradually  they  become  more  distinct  and  nu- 
merous as  the  pulmonary  consolidation  increases.     The 


CHRONIC   PULMONARY    TUBERCULOSIS.  77 

£ 
heart  sounds  over  the  affected  lung  will  be  increased  in 

intensity. 

Vocal  resonance  is  subject  to  so  many  variations  as  to 
render  it  almost  valueless  as  a  means  of  diagnosis.  Ex- 
aggerated vocal  resonance  at  the  left  apex  is  of  some  im- 
portance. 

The  Advanced  Stage  is  marked  by  a  greater  involve- 
ment of  lung  tissue.  The  consolidation  extends,  and  is 
attended  by  softening,  and  the  formation  of  cavities. 
There  is  a  diminution  in  the  volume  of  the  lung,  with 
corresponding  contraction  of  the  chest  walls. 

The  diagnosis  of  a  cavity  demands  that  it  be  near  the 
surface,  Dot  smaller  than  a  walnut,  and  for  the  most 
part  contain  air. 

Inspection. — The  respiratory  acts  are  much  increased 
in  frequency,  and  marked  depression  will  be  noticed 
above  and  below  the  clavicles.  There  is  deficiency  in 
local  expansion,  especially  during  a  full  inspiration  ;  or 
it  may  be  that  the  respiratory  movements  are  arrested 
in  the  supra-  and  infra-clavicular  regions. 

Palpation.  —  The  vocal  fremitus,  as  a  rule,  is  in- 
creased over  the  consolidated  area,  and  over  a  large 
superficial  cavity  when  partially  or  completely  filled. 
Sometimes  a  gurgling  fremitus  may  be  detected. 

Percussion. — Before  cavities  are  formed  there  is  a 
widespread  and  more  intense  dulness  than  in  the  Early 
Stage.  It  often  assumes  a  wooden  or  a  tubular  charac- 
ter. After  the  formation  of  cavities  the  percussion 
sound  varies  according  to  the  condition  of  the  cavi- 
ties themselves  and  the  lung  tissue  surrounding  them. 
If  the  cavity  is  of  small  size  and  surrounded  with  con- 
solidated lung  tissue,  the  percussion  sound  will  be  ab- 
solutely dull  or  tubular  in  quality  ;  if  a  layer  of  healthy 
luns:  tissue  intervene  between  the  chest  walls  and  the 


78  PHYSICAL  DIAGNOSIS. 

cavity,  the  latter  being  full,  gentle  percussion  will  give 
normal  resonance,  while  forcible  percussion  will  elicit 
deep-seated  dulness.  Large,  empty,  superficial  cavities 
with  thin,  tense  walls  yield  an  amphoric  or  "cracked- 
pot  "  resonance. 

Auscultation.  —  Over  consolidated  areas  the  respira- 
tion grows  more  intensely  bronchial,  and  moist,  crack- 
ling rales  of  a  metallic  character  are  heard.  The  rales 
sometimes  are  sticky  in  character,  and  do  not  change  or 
disappear  on  coughing. 

If  a  cavity  is  empty  and  communicates  freely  with  a 
bronchial  tube,  and  no  healthy  lung  tissue  lies  between 
it  and  the  chest  walls,  the  respiration  will  be  either  cav- 
ernous or  amphoric  (as  shown  in  Fig.  4,  page  44)  —cav- 
ernous, when  the  cavity  is  of  small  size,  with  a  flaccid 
wall  that  collapses  with  expiration  and  expands  with  in- 
spiration ;  amphoric,  when  the  cavity  is  large  and  sur- 
rounded with  consolidated  lung,  or  with  a  thick,  fibrous 
wall  that  does  not  collapse  in  expiration.  If  liquid  has 
accumulated  in  the  cavity  in  sufficient  quantity  to  rise 
above  the  opening  into  it,  large  or  small-sized  gurgles 
will  be  heard  (as  shown  in  Fig.  4,  page  44).  Metallic 
tinkling  will  sometimes  be  heard  over  cavities  of  large 
size.  Vocal  resonance  may  be  amphoric,  bronchophonic, 
weak,  or  entirely  absent ;  pectoriloquy  may  be  present. 
Small  cavities  partially  filled  with  liquid,  and  deeply 
seated,  do  not  give  rise  to  the  signs  characteristic  of  cavi- 
ties, but  simply  furnish  blowing  respiration  and  small - 
sized  gurgles,  which  resemble  very  closely  mucous  rales. 

A  cavity  may  be  presumed  to  exist  at  the  point  where 
the  bronchial  breathing  is  most  intense  and  the  moist 
sounds  are  most  metallic  in  quality.  The  difficulty  with 
which  tuberculosis  is  differentiated  from  some  forms  of 
pleurisy  and  pneumonia  has  already  been  indicated. 


HEART 
THORACIC   AORTA. 


LESSOR  IX. 

TOPOGRAPHY  OF  THE  HEART  AND  AORTA — PHYSIOLOGICAL 
ACTION  OP  THE  HEART. 

The  diagnosis  of  many  cardiac  diseases  rests  upon  our 
knowledge  of  the  relations  of  the  different  compart- 
ments and  orifices  of  the  heart  to  the  chest  walls.  It  is 
therefore  necessary  to  be  familiar  with  this  relationship, 
and  with  the  physiological  acts  which  constitute  a  com- 
plete cardiac  cycle,  before  we  can  study  intelligently 
the  physical  signs  involved  in  the  diagnosis  of  these 
diseases. 

By  referring  to  Fig.  1,  page  5,  the  relations  of  the 
heart  to  the  adjacent  viscera  will  be  readily  appreciated. 

In  the  healthy  chest,  the  auricles  are  on  a  line  with 
the  third  costal  cartilages.  The  right  auricle  extends 
across  the  sternum,  a  little  beyond  its  right  border. 
The  left  auricle  lies  deeply  behind  the  pulmonary  artery. 
The  middle  portion  of  this  auricle  corresponds  to  the 
cartilage  of  the  third  rib.  The  right  ventricle  lies  partly 
behind  the  sternum,  and  partly  to  the  left  of  it ;  its  in- 
ferior border  is  on  a  level  with  the  sixth  cartilage.  The 
left  ventricle  lies  for  the  most  part  to  the  left  of  the  ster- 
num, between  the  third  and  fifth  intercostal  spaces. 
Only  a  narrow  strip  of  the  ventricle  is  visible  anteriorly. 
The  heart,  then,  as  a  whole,  extends  vertically  from  the 
second  space  to  the  sixth  costal  cartilage,  and  transverse- 
ly from  about  half  an  inch  to  the  right  of  the  sternum 
to  within   an  inch  of  the  left  nipple  line.     Posteriorly, 


82  PHYSICAL   DIAGNOSIS. 

the  base  lies  opposite  the  sixth  and  seventh  dorsal  ver- 
tebras. The  left  ventricle,  the  greater  part  of  the  left 
auricle,  and  a  large  portion  of  the  apex  of  the  right  ven- 
tricle, He  to  the  left  of  the  sternum.  Behind  the  ster- 
num He  a  greater  portion  of  the  right  auricle  and  ven- 
tricle, and  a  small  portion  of  the  left.  To  the  right  of 
the  sternum  lie  a  portion  of  the  right  auricle  and  the 
upper  portion  of  the  right  ventricle.  The  whole  of  the 
anterior  surface  of  the  heart  is  overlapped  by  the  lungs, 
excepc  a  triangular  space  corresponding  to  the  lower 
portion  of  the  right  ventricle. 

The  Surface  Measurements  of  the  heart  are  as  fol- 
lows :  Vertical  measurement  from  the  second  interspace 
to  the  fifth  interspace,  five  inches  ;  from  the  median 
line  to  the  left,  on  the  third  rib,  two  and  a  half  to  three 
inches  ;  on  the  fourth  rib,  from  three  and  a  half  to  f oui 
inches  ;  in  the  fifth  interspace,  from  three  to  three  and 
a  half  inches. 

Relative  Position  of  the  Valves. 

The  Tricuspid  Valve  Hes  behind  the  middle  of  the 
sternum,  at  the  level  of  the  fourth  costal  cartilage. 

The  Mitral  Valve  Hes  behind  the  third  intercostal 
space,  about  one  inch  from  the  sternum.  It  is  the 
deepest  of  all. 

The  Aortic  Valves  He  behind  the  sternum,  near  its 
left  edge,  a  little  below  the  junction  of  the  third  costal 
cartilage. 

The  Pulmonary  Valves  lie  behind  the  junction  of  ♦ 
the  third  left  costal  cartilage  with  the  sternum.  A  circle 
of  an  inch  in  diameter  with  its  centre  at  the  left  edge  of 
the  sternum,  a  Httle  below  the  junction  of  the  third  rib 
with  the  sternum,  will  include  a  portion  of  all  these  four 
sets  of  valves. 


PHYSIOLOGICAL   ACTION   OF   THE    HEART.  83 

The  Aorta  arises  from  the  left  ventricle,  behind  the 
sternum,  opposite  the  third  intercostal  space,  and  passes 
from  left  to  right.  The  ascending  portion  of  the  arch 
comes  to  the  right  of  the  sternum  between  the  cartilages 
of  the  second  and  third  ribs.  In  this  part  of  its  course 
it  is  within  the  pericardial  sac.  Thence  the  transverse 
portion  of  the  arch  crosses  the  trachea  just  above  its  bi- 
furcation (at  the  centre  of  the  first  bone  of  the  ster- 
num), and,  passing  backward  and  downward  toward 
the  left  side  of  the  third  dorsal  vertebra,  becomes  the  de- 
scending portion.  It  rests  ultimately  upon  the  left  side 
of  the  bodies  of  the  fifth  and  sixth  dorsal  vertebrae. 
The  arch  of  the  aorta  approaches  most  closely  to  the 
chest  walls  at  the  point  where  the  arteria  innominata  is 
given  off — that  is,  on  a  line  with  the  junction  of  the  car- 
tilage of  the  second  right  rib  with  the  sternum. 

The  Pulmonary  Artery  arises  from  the  right  ven- 
tricle, to  the  left  and  behind  the  sternum,  on  a  line  with 
the  junction  of  the  cartilages  of  the  third  ribs  with  the 
sternum.  It  passes  upward  and  backward  about  two 
inches,  when  it  bifurcates  opposite  the  second  costal  car- 
tilage. 

The  Pericardial  Sac  encloses  the  heart,  and  may  be 
represented  as  a  cone,  extending  from  the  second  to  the 
seventh  left  costal  cartilage.  The  base  of  the  cone  rests 
on,  and  is  attached  to,  the  diaphragm,  and  the  apex  em- 
braces the  lower  two  inches  of  the  great  vessels.  The 
larger  portion  of  the  sac  lies  to  the  left  of  the  median 
line,  and  is  further  from  the  anterior  chest  wall  su- 
periorly than  it  is  inf erioiiy. 

Physiological  Action  of  the  Heart. 
A  contraction  of  the  heart  begins  in  the  great  veins 
and  proceeds  as  a  peristaltic  wave  to  the  auricles.     They 


84 


PHYSICAL  DIAGNOSIS. 


rapidly  contract,  and  are  immediately  followed  by  the 
ventricular  contraction,  or  systole.  After  a  contraction 
the  muscular  tissue  relaxes,  and  a  period  of  rest  ensues, 
the  diastole.  A  complete  cardiac  cycle  consists  of  the 
contraction  and  dilatation  of  each  of  the  cavities  of 
the  heart.  During  the  ventricular  systole  there  is  a 
change  in  its  form,  size,  and  position. 

Auricular  Diastole. — The  blood  is  pouring  from 
the  great  veins  into  the  auricles,  and  through  the  auri- 
culo-ventricular  openings    into    the    ventricles    below. 


Fig.  9.— Diagrammatic  representation  of  the  Changes  that  occur  in  the  Valves  and 
Cavities  of  One  Side  of  the  Heart  during  a  Cardiac  Cycle. 


The  semilunar  valves  are  closed,  as  seen  in  Fig.  9. 
When  the  auricles  become  distended  the 

Auricular  Systole  begins.  As  it  progresses  they 
become  smaller,  and  their  walls  crowd  toward  the 
opening  into  the  ventricles  below,  forcing  a  small  quan- 
tity of  blood  before  them.  The  semilunar  valves  still 
remain  closed. 

Ventricular  Systole. — The  contraction  of  the  au- 
ricles completely  fills  the  ventricles  with  blood.  At  the 
same  time,  it  is  supposed,  the  flaps  of  the  mitral  and  tri- 
cuspid valves  are  floated  into  place  by  reflex  currents 


PHYSIOLOGICAL   ACTION   OF   THE    HEART.  85 

along  the  sides  of  the  cavities.  Everything  is  now 
ready  for  contraction.  Suddenly  the  ventricular  walls 
become  tense  and  hard,  the  shape  of  the  heart  becomes 
more  distinctly  conical,  and  it  rotates  on  its  long  axis 
from  left  to  right,  bringing  more  of  the  left  ventricle  to 
the  front.  The  systole  is  complete.  The  blood  has  been 
forced  into  the  aorta  and  pulmonary  arteries  respec- 
tively. During  its  passage  the  cusps  of  the  semilunar 
valves  have  been  pressed  toward,  but  not  against,  the 
arterial  walls.  Any  reflux  of  blood  into  the  auricles,  Or 
even  bulging  of  the  auriculo-ventricular  valves,  is  pre- 
vented by  the  contraction  of  the  muscular  papillae. 
They  draw  upon  the  chordae  tendineae,  and  hold  the  flaps 
in  close  apposition.  The  cardiac  impulse  is  synchronous 
with  the  ventricular  systole,  and  is  caused  by  the  impact 
of  the  rigid  heart  against  the  chest  wall.  It  is  most  dis- 
tinctly felt  in  the  fifth  intercostal  space,  just  to  the  me- 
dian side  of  the  mammillary  line.  The  first  sound  of 
the  heart  is  heard  with  the  ventricular  contraction,  and 
is  of  a  loud,  " booming"  character.  It  is  probably  of 
combined  muscular  and  valvular  origin. 

Ventricular  Diastole. — -After  a  short  interval  the 
second  sound  is  heard.  It  is  sharp  and  sudden  in  cha- 
racter, and  is  caused  by  the  closure  of  the  semilunar 
valves.  At  its  occurrence  the  ventricles  have  just  fin- 
ished their  systole  and  are  beginning  to  relax.  Then 
succeeds  the  diastole.  The  ventricular  walls  become 
flaccid,  the  heart  returns  to  its  former  position,  the 
valves  at  the  mitral  and  tricuspid  orifices  open,  and  the 
blood  flows  in  from  the  auricles,  preparatory  to  the  com- 
mencement of  another  cycle.  The  semilunar  valves  are 
closed  by  the  negative  pressure  produced  at  the  end  of 
the  systole,  or  by  the  elastic  recoil  of  the  over-distended 
arteries. 


86 


PHYSICAL   DIAGNOSIS. 


Duration  of  the  Different  Phases. — The  ventricu- 
lar systole  occupies  about  three-eighths  of  an  entire 
cardiac  cycle ;  the  auricular  systole,  about  one-eighth  • 
and  the  diastole  of  the  auricles  and  ventricles,  about 
one-half. 

But  it  must  be  remembered  that  the  ventricles  are  at 
rest  also  during  the  auricular  systole  ;  so  it  will  be  seen 
that  they  work  less  than  one-half  the  time. 

Fig.   10  well  illustrates  the  sequence  of  events  in  a 


Fig.  10.— Representation  of  the  Movements  and  Sounds  of  the  Heart  during  a  Car- 
diac Cycle  —Dr.  Sharpey. 

cardiac  cycle.     It  is  not  intended  that  its  measurements 
shall  be  exact. 

The  normal  pulse  rate  of  the  heart  is  Y2  to  the  minute, 
though  it  varies  coasiderably  in  different  individuals, 
and  in  the  same  individual  at  different  times.  Thus,  it 
is  more  rapid  in  women  and  children  than  in  men,  and 
it  becomes  accelerated  after  a  full  meal.  A  rapidly  beat- 
ing heart  differs  from  a  slowly  beating  heart  chiefly  in 
the  length  of  its  diastole.  As  the  length  of  the  diastole 
increases,  the  greater  becomes  the  interval  between  the 
second  and  first  sounds  of  the  heart.  Fig.  11  is  a  series 
of  circles  representing  the  altered  relations  of  the  sounds 


DURATION    OF    THE    DIFFERENT    PHASES. 


87 


in  slowed  or  accelerated  heart  action.  The  first  and 
second  sounds  correspond,  respectively,  to  radii  1  and  2. 
The  larger  circumference  of  each  successive  circle  in- 
dicates the  lengthening  of  the  pause.  The  interval  be- 
tween the  first  and  second  sounds  becomes  relatively 
shortened  as  the  heart's  action  is  slowed,  and  is  repre- 
sented by  a  smaller  arc;  while  the 
interval  between  the  second  and  first 
sounds  is  lengthened.  In  the  first 
and  smallest  circle,  indicating  the 
most  rapid  action,  the  two  intervals 
are  nearly  equal,  and  each  occupies 
about  one-half  the  circumference  ;  in 
the  last  or  largest  circle  the  interval 
between  the  second  and  first  sounds 
is  about  four  times  as  long  as  that 
between  the  first  and  second.  Hence 
it  is  that,  when  the  heart  is  acting 
rapidly,  it  is  difficult  to  distinguish 
the  first  sound  from  the  second,  and 
vice  versa ;  while  with  the  slowly 
acting  heart  this  difficulty  does  not 
occur.  Attention  to  these  varieties 
— physiological  varieties  they  may 
be  called — in  the  rhythm  of  the 
sounds  is  of  very  great  importance  in  determining  the 
attributes  of  a  cardiac  murmur,  for  the  first  step  in 
the  inquiry  is  to  determine  which  is  the  second  sound 
and  which  is  the  first.  This,  as  I  have  said,  is  sometimes 
not  an  easy  matter.  Generally  speaking,  and  in  all  cases 
when  the  action  is  slow  and  regular,  there  is  no  diffi- 
culty. You  have  only  to  remember  that  the  longer 
interval  is  between  the  second  and  first  sounds,  and  the 
shorter  interval  between  the  first  and  second.    But  when 


88  PHYSICAL   DIAGNOSIS. 

the  action  is  rapid  or  irregular,  and  when  the  first  sound 
is  indistinct  at  the  apex,  or  cannot  be  identified  with  the 
apex  beat,  and  also  when  the  second  sound  is  indistinct, 
or  when  it  is  audible  only  at  the  base,  the  first  sound 
being  audible  only  at  the  apex,  as  sometimes  happens, 
the  difficulty  of  recognition  of  the  two  sounds  is  very 
considerable. 


LESSOR  X. 

METHODS   OF   CARDIAC   PHYSICAL  EXAMINATION. 

The  methods  of  physical  examination  of  the  heart  in- 
clude inspection,  palpation,  mensuration,  percussion, 
and  auscultation. 

By  Inspection  you  note  the  exact  point  of  the  heart's 
impulse  against  the  chest  wall,  whether  there  is  any  un- 
usual pulsation,  or  any  change  in  the  form  of  the  cardiac 
region.  In  a  perfectly  normal  chest,  the  infra-mam- 
mary regions  on  either  side  are  very  nearly  symmetrical ; 
but  in  disease  the  precordial  region  may  be  depressed, 
or  arched  forward,  and  the  intercostal  spaces  may  be 
widened.  The  most  important  information  furnished 
by  inspection  relates  to  the  cardiac  impulse.  This,  in 
the  majority  of  persons,  is  visible  only  in  the  fifth  inter- 
space, midway  between  the  left  nipple  and  the  sternum, 
and  its  area  does  not  exceed  a  square  inch.  You  will 
find  it  most  distinct  in  thin  persons,  while  in  fleshy  per- 
sons it  is  sometimes  not  discernible.  You  will  find  also 
that  it  may  be  displaced  by  a  change  of  position,  by  dis- 
tention of  the  subjacent  stomach,  and  by  the  movements 
of  respiration.  Thus,  during  a  full  inspiration  you  may 
see  the  impulse  lowered  an  intercostal  space,  and  then 
during  a  forced  expiration  see  it  elevated  and  more 
diffused. 

Change  in  the  situation  of  the  impulse  may  result 
from  disease  of  the  heart  itself,  disease  of  the  pericar- 
dium   or   of  the   adjacent   viscera.     In   cardiac   hyper- 


90  PHYSICAL  DIAGNOSIS. 

trophy  it  is  displaced  downward  and  to  the  left,  while 
in  pericardial  effusion  it  is  displaced  upward.  It  may 
be  carried  upward  and  to  the  left  by  enlargement  of  the 
left  lobe  of  the  liver,  or  downward  and  to  the  right 
by  simple  pleuritic  effusion  or  emphysema.  I  have  seen 
the  impulse  even  external  to  the  right  nipple.  Not  in- 
frequently in  cases  of  pericardial  agglutination,  or  dila- 
tation of  the  ventricles,  an  undulating  impulse  will  be 
visible. 

When  from  any  cause  the  impulse  cannot  be  seen,  its 
position  must  be  determined  by  palpation. 

Palpation. — This  is  of  much  greater  clinical  impor- 
tance than  inspection.  By  it  we  determine  the  force  of 
the  cardiac  pulsation,  the  frequency  or  slowness  of  the 
heart's  action,  and  the  regularity  or  irregularity  of  its 
movements.  By  it,  also,  we  detect  the  presence  of  the 
friction  fremitus,  and  what  is  termed  the  "purring 
thrill." 

The  force  of  the  cardiac  impulse  may  be  diminished  or 
increased. 

Diminution  in  the  force  of  the  impulse  may  be  due  to 
degeneration  of  the  heart  wall,  or  to  prostration  of  the 
whole  system,  as  in  collapse.  It  is  also  diminished  when 
the  apex  is  prevented  from  impinging  against  the  wall 
of  the  chest  with  its  customary  force,  as  happens  in  dis- 
ease of  the  lungs  or  pericardium. 

Increase  in  the  force  of  the  impulse. — In  the  ma- 
jority of  instances,  this  is  caused  by  hypertrophy  of  the 
walls  of  the  left  ventricle.  A  slow,  progressive  impulse 
can  be  produced  by  no  other  cause.  In  such  cases, 
the  area  over  which  the  cardiac  impulse  can  be  felt  is 
much  increased.  In  the  early  stage  of  endocarditis  and 
pericarditis,  and  in  palpitations  from  functional  disor- 
der:;, tho  impulse  is  slightly  increased. 


PERCUSSION.  91 

The  frequency  and  regularity  of  the  heart's  action  is 
of  great  importance  in  the  diagnosis  of  cardiac  disease. 
It  can  often  be  most  accurately  determined  by  palpation. 

The  Purring  Thrill  (the  "  fremissement  cataire"  of 
Laennec)  is  a  peculiar  vibratory  sensation  perceptible  on 
making  pressure  at  the  precordium.  In  some  the  pres- 
sure need  be  but  slight,  while  in  others  it  should  be  firm. 
It  may  also  be  communicated  by  the  large  arteries,  etc. 

Percussion. — By  percussion  we  aim  to  determine  the 
exact  outline  of  the  heart  and  of  its  investing  membrane, 
to  see  whether  it  exceeds  its  normal  area.  In  perform- 
ing cardiac  percussion  you  will  find  both  care  and  pa- 
tience necessary  to  obtain  accurate  results.  The  patient 
should  be  in  a  recumbent  posture.  You  need  tap  but 
lightly  over  the  part  where  the  heart  is  not  covered  by 
lung  tissue,  to  obtain  a  flat  sound  ;  but  where  the  lungs 
overlap  the  organ,  you  must  percuss  more  forcibly  to 
elicit  cardiac  dulness,  and  this  sound  will  of  necessity 
have  more  or  less  of  a  pulmonary  quality.  We  have, 
therefore,  two  degrees  of  cardiac  dulness— the  super- 
ficial and  the  deep-seated.  In  health  the  area  of  the 
superficial  dulness  does  not  exceed  two  inches  in  any  di- 
rection. It  is  triangular  in  form,  with  the  apex  imme- 
diately below  the  junction  of  the  left  third  rib  with  the 
sternum,  while  the  base  is  on  a  line  with  the  cartilage  of 
the  sixth  rib.  The  area  of  the  deep-seated  dulness  in 
health  extends  transversely  from  the  left  nipple  to  half 
an  inch  to  the  right  of  the  sternum,  and  vertically  from 
the  second  to  the  sixth  interspace. 

The  area  of  the  heart's  superficial  dulness  may  be  in- 
creased or  diminished  :  increased,  when  the  ventricles 
are  hypertrophied,  or  when  their  cavities  are  dilated, 
and  also  when  the  pericardium  contains  liquid  ;  dimin- 
ished, at  the  end  of  a  full  inspiration,  and  in  pulmonary 


92  PHYSICAL   DIAGNOSIS. 

emphysema  where  there  is  a  general  distention  of  the 
air  cells.  The  area  of  the  deep-seated  dulness  is  in- 
creased by  enlargement  of  the  heart,  whether  this  be 
due  to  ventricular  dilatation  or  to  hypertrophy  of  its 
walls.  It  is  apparently  increased  by  consolidation  of 
the  anterior  border  of  the  investing  lung,  and  by  liquid 
in  the  left  pleural  cavity.  We  are  often,  in  certain 
cases,  much  assisted  in  determining  the  limits  of  the 
deep-seated  dulness  by  auscultatory  percussion. 

Auscultation. — For  reasons  already  stated  I  prefer 
mediate  to  immediate  auscultation  in  examining  the 
heart,  and  in  practising  it  you  will  find  the  following 
simple  rules  of  service  : 

1.  The  posture  of  the  "patient  should  be  recumbent 
when  you  begin  your  examination.  Then,  having  care- 
fully elicited  all  the  auscultatory  signs  which  this  pos- 
ture affords,  repeat  your  examination  with  him  sitting 
or  standing,  and  note  whether  any  variations  in  the 
sounds  heard  have  occurred  from  the  change  in  his 
position. 

2.  You  should  first  listen  to  the  heart  sounds  while 
the  patient  is  breathing  naturally  ;  having  done  so,  then 
direct  him  to  hold  his  breath  for  a  moment  ;  and  finally 
tell  him  to  take  three  or  four  forced  inspirations.  All  of 
these  means  are  often  requisite  before  we  can  correctly 
discriminate  between  the  different  signs  of  cardiac  aus- 
cultation. 

3.  You  should  not  confine  your  examination  to  the 
precordial  region  alone,  but  should  explore  the  whole 
thoracic  cavity,  and  endeavor  to  localize  the  points  at 
which  the  heart  sounds,  both  normal  and  abnormal,  are 
heard  with  the  greatest  intensity.  To  this  end  proceed 
in  your  examination  from  below  upward,  and  from 
left  to  right. 


INTENSITY    OF    HEART    SOUNDS.  93 

As  in  the  case  of  pulmonary  auscultation,  so  here,  the 
normal  characters  must  he  the  starting-point  or  standard 
to  which  every  sound  in  cardiac  auscultation  is  to  be 
compared.  You  cannot,  therefore,  pay  too  much  atten- 
tion to  acquiring  a  familiarity  with  the  elements  of  the 
heart  sounds  in  health.  These  elements  are  as  follows  : 
When  the  ear  or  stethoscope  is  applied  to  the  precordial 
region,  two  successive  sounds  are  heard,  followed  by  an 
interval  of  silence.  The  first  sound  is  softer,  lower  in 
pitch,  and  more  prolonged  than  the  second  ;  as  has  al- 
ready been  shown  in  Fig.  10,  it  coincides  with  the  sys- 
tole of  the  ventricles  and  with  the  apex  beat.  It  imme- 
diately precedes  the  radial  pulse,  and  has  its  maximum 
of  intensity  in  the  fifth  interspace,  a  little  to  the  right  of 
the  left  nipple  line.  The  second  sound  is  sharper,  or 
higher  pitched,  shorter  and  more  superficial  than  the 
first.  It  marks  the  beginning  of  the  ventricular  dias- 
tole, occurs  after  the  pulsation  of  the  arteries,  and  has 
its  maximum  of  intensity  at  the  junction  of  the  third 
left  rib  with  the  sternum. 

The  period  of  silence  immediately  following  the  sec- 
ond sound  varies  in  length  with  the  rapidity  of  the 
heart's  action.  The  order  and  duration  of  the  sounds, 
and  the  silence,  you  will  be  able  to  appreciate  best  by  re- 
ferring to  diagrams  Nos.  10  and  11  (pages  86  and  87). 

The  intensity  of  the  heart  sounds  varies  in  health  ac- 
cording to  the  force  of  the  heart's  action,  or  according 
to  the  conformation  of  the  chest,  or  according  to  indi- 
vidual idiosyncrasies.  These  sounds  are  less  intense  in 
fleshy  or  muscular  persons  with  capacious  chests  than 
in  thin,  narrow-chested,  and  nervous  individuals. 

The  extent  of  surface  over  which  the  heart  sounds  are 
heard  varies  with  the  adaptation  of  the  adjacent  organs 
for  transmitting  sounds.     Generally  speaking,  the  sounds 


94  PHYSICAL   DIAGNOSIS. 

produced  on  the  right  side  of  the  heart  are  more  audible 
on  the  right  side  of  the  precordial  region,  while  those 
produced  on  the  left  are  more  pronounced  on  the  cor- 
responding side. 

Pathological  Modifications  op  the  Normal 
Sounds. — In  disease  the  normal  sounds  of  the  heart 
present  various  alterations  as  regards  their  intensity, 
quality,  pitch,  seat,  and  rhythm.  They  may  also  be 
accompanied,  preceded,  or  followed  by  adventitious 
sounds  or  murmurs. 

An  increase  of  intensity  may  be  noted  in  cases  of 
hypertrophy  and  dilatation  of  the  ventricles,  in  cases  of 
nervous  irritability  of  the  heart,  or  where  there  is  con- 
solidation of  the  adjacent  lung  tissue.  A  diminution 
in  intensity  may  be  found  depending  either  upon  dilata- 
tion of  the  ventricles  without  hypertrophy  of  their 
walls  ;  upon  fatty  degeneration  of  the  muscular  tissue 
of  the  heart ;  upon  the  granular  or  hyaline  changes 
occurring  in  infectious  fevers  ;  or  it  may  be  owing  to 
a  muffling  of  the  heart  sounds  by  pericardial  effusion, 
or  by  emphysematous  distention  of  the  anterior  border 
of  the  lung. 

Alterations  in  Quality  and  Pitch.— The  heart  sounds 
in  disease  may  become  dull  and  low-pitched,  or  sharp 
and  high-pitched.  The  first  sound  is  dull,  muffled,  and 
low-pitched  when  hypertrophy  is  conjoined  with  a 
thickened  condition  of  the  auriculo- ventricular  valves. 
On  the  other  hand,  where  the  ventricular  walls  are  thin 
and  the  valves  natural,  the  first  sound  becomes  sharp 
and  clicking  in  character,  and  the  pitch  is  raised.  The 
second  sound  is  rendered  dull  and  low-pitched  by 
diminished  elasticity  of  the  arterial  walls,  and  by  thick- 
ening of  the  aortic  valves,  without  regurgitation.  Some- 
times the  heart  sounds  have  a  metallic  or  tinkling  qual- 


IRREGULARITY  IX  THE  HEART  SOUNDS.        95 

ity,  which  depends  either  upon  an  irritable  action  of  the 
heart  or  on  a  gaseous  distention  of  the  stomach. 

Alterations  in  Seat. — This  refers  to  the  points  of 
maximum  intensity  of  the  respective  sounds.  They 
may  be  displaced  upward  by  certain  changes  in  the  ab- 
dominal viscera  ;  or  downward  by  tumors  in  the  me- 
diastinum, and  by  hypertrophy  with  dilatation  of  the 
auricles  ;  or  laterally  by  the  accumulation  of  air  or  liquid 
in  the  pleural  cavities.  Malformations  of  the  thorax 
may  likewise  displace  them  in  different  directions. 

Alterations  in  Rhythm. — It  not  infrequently  happens 
that  a  distinct  intermission  occurs  in  the  heart's  action. 
After  a  certain  number  of  regular  beats,  a  sudden  pause 
or  silence  occurs  ;  the  heart's  action  seems  to  be  sus- 
pended for  an  instant,  and  then  to  go  on  regularly. 
This  intermission  is  often  observed  in  individuals  who 
are  in  perfect  health.  It  also  occurs  in  diseased  states  of 
the  valves  or  orifices  of  the  heart.  It  is  difficult  to  ex- 
plain its  cause,  and  it  has  no  precise  pathological  signifi- 
cance. 

Irregularity  in  the  Heart  Sounds,  however,  constitutes 
another  and  different  alteration  in  rhythm.  The  sounds 
become  confused  and  tumultuous  ;  they  are  alternately 
loud  and  feeble  ;  at  one  time  slow  for  two  or  three  beats, 
and  then  they  follow  each  other  in  rapid  succession. 
When  the  irregularity  is  permanent,  it  is  almost  positive 
evidence  of  organic  disease  of  the  heart,  the  most  fre- 
quent form  being  contraction  of  the  mitral  valves. 

One  or  both  of  the  heart  sounds,  as  well  as  the  period 
of  rest,  may  be  prolonged  or  shortened.  In  hypertrophy 
of  the  ventricular  walls  the  first  sound  is  prolonged,  in 
dilatation  of  the  cavities  of  the  ventricles  it  is  shortened. 
The  first  sound  is  also  prolonged  when  the  two  sur- 
faces of  the  pericardium  are  adherent.     An  obstacle  to 


96  PHYSICAL   DIAGNOSIS. 

the  flow  of  the  blood  into  the  ventricles  prolongs  the 
period  of  repose.  Another  alteration  in  the  rhythm  of 
the  heart  sounds  is  named  reduplication.  Each  systolic 
sound  may  be  repeated  twice  for  one  diastolic,  or  the 
diastolic  may  occur  twice  for  one  systolic.  Sometimes 
only  one  sound  is  audible. 

The  essential  cause  of  the  various  reduplications  seems 
to  be  a  want  of  synchronism  between  the  action  of  the 
two  sides  of  the  heart.  It  may  occur  at  all  ages,  and  is 
as  common  with  one  sound  as  with  the  other.  Intermit- 
tence  is  an  almost  constant  character  of  reduplication, 
the  sound  being  doubled  with  some  beats  of  the  heart, 
and  not  with  others.  This  intermittence  in  some  in- 
stances is  undoubtedly  connected  with  the  movements 
of  respiration.  In  laborious  respiration  the  first  sound 
may  be  doubled  at  the  end  of  inspiration  and  the  begin- 
ning of  expiration,  and  the  second  sound  at  the  end  of 
expiration  and  the  beginning  of  inspiration.  Clinically, 
it  is  important  to  distinguish  true  doubling  of  the  sounds 
from  those  false  reduplications  which  are  in  reality  com- 
pounded of  a  sound  and  a  murmur. 


LESSOR  XI 

ABNORMAL  SOUNDS  OF  THE  HEART. 

Pericardial  and  Endocardial  Murmurs. 

The  term  murmyrs  has  been  applied  to  those  adven- 
titious sounds  which  accompany  or  replace  the  normal 
sounds  of  the  heart,  and  which  are  not  heard  in  health. 
Their  seat  may  be  either  within  the  heart  at  the  orifices 
of  the  ventricles,  when  they  are  called  endocardial  or 
valvular  murmurs  ;  or  they  may  be  external  and  in  the 
pericardium,  when  they  are  termed  exocardial  or  peri- 
cardial friction  sounds. 

Pericardial  Friction  Sounds. — The  pericardium  is  a 
serous  membrane  investing  the  heart,  as  the  pleura  in- 
vests the  adjacent  lung.  We  have,  therefore,  when  it 
is  inflamed,  results  analogous  to  those  which  we  de- 
scribed as  appertaining  to  pleurisy — namely,  dryness, 
and  then  plastic  exudation,  with  the  different  friction 
sounds  which  are  caused  by  the  rubbing  of  the  rough- 
ened surfaces  upon  one  another  during  the  movements 
of  the  heart,  and,  lastly,  the  serous  effusion.  This  simi- 
larity sometimes  makes  it  a  nice  point  in  diagnosis  to 
distinguish  a  pericarditis  from  a  pleurisy.  In  pericardi- 
tis the  sounds  are  limited  to  the  precordial  area  ;  they 
are  synchronous  with  the  cardiac  rather  than  the  respi- 
ratory movements,  and  do  not  cease  when  the  patient 
holds  his  breath. 

The  different  forms  of  the  pericardial  friction  sounds 
have  been  named,  like  those  in  pleurisy,  grazing,  rub- 
bing, creaking,  rasping,  etc.  Clinical  experience,  however, 
does  not  always  show  any  definite  connection  between 


98  PHYSICAL,  DIAGNOSIS. 

the  state  of  the  serous  surfaces  and  the  quality  of  a  fric- 
tion sound.  The  grazing  variety  belongs  to  the  initial 
stage  of  the  inflammation  ;  the  other  varieties  occur 
after  the  plastic  effusion,  and  while  it  is  undergoing  or- 
ganization. These  sounds  vary  in  intensity  from  the 
slight  rustling  which  can  be  heard  only  by  close  atten- 
tion, to  a  loud  rasping  sound  audible  before  your  ear  is 
applied  to  the  chest.  As  a  rule,  they  become  more  dis- 
tinct during  expiration  than  inspiration,  and  while  the 
patient  is  sitting  rather  than  while  recumbent,  owing 
to  the  greater  approximation  of  the  pericardium  to  the 
chest  wall  during  these  states. 

Pericardial  friction  sounds  may  be  single  or  double — 
that  is,  accompanying  both  the  systolic  and  the  diastolic 
movements,  or  either  one  singly.  They  may  accom- 
pany the  valvular  sounds,  or  be  independent  of  them. 
They  usually  convey  the  impression  of  being  superficial 
in  comparison  with  the  endocardial  murmurs.  They 
are  generally  restricted  to  the  pericardial  space,  the 
point  of  maximum  intensity  being  usually  at  the  junc- 
tion of  the  fourth  rib  with  the  sternum.  They  do  not 
often  last  long,  disappearing  frequently  after  a  few 
hours,  or  at  most  in  a  few  days. 

A  pericardial  murmur  is  distinguished  from  an  endo- 
cardial by  its  rubbing  quality,  by  its  superficial  charac- 
ter, and  by  its  not  being  transmitted  beyond  the  limits  of 
the  heart,  either  along  the  arteries  or  round  the  left  side 
to  the  back.  It  may  also  be  distinguished  from  a  val- 
vular murmur  by  its  intensity  varying  with  a  change  in 
the  position  of  the  patient,  and  by  its  independence  of 
the  heart  sounds. 

Endocardial  or  Valvular  Murmurs. 
In  endocardial  murmurs  the  elements  of  quality  and 


THE   RHYTHM    OF   A   MURMUR.  99 

intensity  hold  but  a  subordinate  place  as  regards  either 
diagnosis  or  prognosis.  The  same  murmur  may  be,  at 
different  times,  blowing,  grating,  rubbing,  or  musical  in 
character,  without  its  significance  altering  in  the  least 
through  all  these  changes  in  its  quality.  "The  mere 
fact  that  a  murmur  exists,  and  has  a  certain  acoustic 
quality,  tells  very  little  as  regards  the  true  character  of 
a  case."  Practically  speaking,  endocardial  murmurs 
may  be  regarded  as  "audible  announcements"  that 
something  has  occurred  to  roughen  the  surfaces  of  the 
endocardium,  or  to  constrict  the  orifices  of  the  heart,  or 
to  render  the  valves  insufficient  so  that  they  allow  the 
blood  to  regurgitate,  or  to  diminish  the  elasticity  of  the 
great  vessels,  or,  finally,  that  some  change  has  taken 
place  in  the  natural  constituents  of  the  blood  itself. 
Anomalous  chordae  tendinese,  wdien  crossing  the  cavity 
of  the  heart  near  its  base,  sometimes  give  rise  to  a  musi- 
cal murmur. 

Having  ascertained  the  existence  of  a  cardiac  mur- 
mur, the  first  question  then  is,  What  is  its  pathological 
significance,  or  in  what  way  has  it  been  produced  ?  To 
determine  this  it  is  necessary  to  observe  particularly 
two  points  :  1st,  The  rhythm ;  and,  2d,  The  seat  of  the 
murmur. 

The  Ehythm  of  a  Murmur. — By  rhythm  we  mean 
the  relation  of  a  murmur  to  the  different  phases  of  the 
cardiac  cycle.  We  speak  of  the  murmur  as  occurring 
with  the  auricular  or  ventricular  systole,  or  during  the 
rest  wmich  intervenes  between  the  periods  of  activity. 
To  determine  its  rhythm  you  must  carefuUy  note  its  re- 
lation to  the  normal  sounds,  the  impulse,  and  the  radial 
pulse. 

Evidently,  the  first  step  is  to  determine  which  is  the 
first  and  which  is  the  second  sound  of  the  heart.    When 


100 


PHYSICAL    DIAGNOSIS. 


the  heart's  action  is  slow  and  regular,  this  is  an  easy 
matter,  but  when  it  is  rapid  it  is  always  difficult,  and 
sometimes  impossible,  to  distinguish  the  one  sound  from 
the  other.  It  is  important,  therefore,  not  only  to  know 
theoretically  all  the  appreciable  phenomena  of  the  phy- 
siological action  of  the  heart,  but  to  have  a  practical 
familiarity  with  them. 

Having  identified  the  two  sounds,  and  noted  their  rela- 
tion to  the  apex  beat  and  radial  pulse,  the  rhythm  of  a 
murmur  is  readily  determined ;   for  all  valvular  mur- 


Fig.  12.— Diagram  illustrating  the  mode  of  production  of  Cardiac  Murmurs  in  the 
Left  Heart,  and  the  condition  of  the  Valves  and  Cavities  durin-r  their  production.  By 
substituting  the  words  "tricuspid'1  and  "pulmonary  "  for  "mitral"  and  "aortic," 
the  diagram  will  similarly  illustrats  murmurs  oscurring  in  the  right  heart. 

murs  either  precede,  or  take  the  place  of,  or  immediately 
follow  one  of  the  heart  sounds. 

First.  A  murmur  may  precede  and  run  up  to  the  first 
sound,  ending  at  the  commencement  of  the  sound,  and 
with  the  apex  beat.  In  this  case,  as  shown  by  Fig.  12, 
the  murmur  is  simultaneous  with  the  contraction  of  the 
auricles,  and  is  either  a  mitral  or  tricuspid  obstructive 
murmur,  according  as  it  is  produced  on  the  right  or  left 
side  of  the  heart   while  the  blood  is  passing  from  the 


THE   RHYTHM   OP   A   MURMUR.  101 

auricles  to  the  ventricles.  Such  murmurs,  therefore,  de- 
pend upon  contraction  of  the  mitral  or  tricuspid  orifices, 
or  upon  deposits  on  the  auricular  surface  of  these  valves, 
causing  obstruction  to  the  outflow  of  blood  from  the 
auricle. 

Second.  A  murmur  may  take  the  place  of,  or  follow, 
the  first  sound,  ending  somewhere  between  the  first  and 
second  sounds.  In  this  case  the  murmur  is  coincident 
with  the  contraction  and  emptying  of  the  ventricles,  and 
must  be  caused,  as  is  shown  in  Fig.  12,  either  by  obstruc- 
tion to  the  current  of  blood  as  it  flows  outward  from  the 
ventricles,  in  its  natural  direction  into  the  aorta  and  pul- 
monary artery ;  or  backward,  by  regurgitation,  through 
the  mitral  or  tricuspid  valves.  If  it  occur  on  the  left  side 
of  the  heart,  it  is  either  an  aortic  obstructive  or  a  mitral 
regurgitant  murmur  ;  if  it  occur  on  the  right  side  of  the 
heart,  it  is  either  a  pulmonic  obstructive  or  a  tricuspid 
regurgitant  murmur. 

TJiird.  A  murmur  may  take  the  place  of,  or  follow, 
the  second  sound,  ending  somewhere  during  the  interval 
between  the  second  and  first  sounds  :  in  some  instances 
it  may  be  prolonged  through  the  whole  period  of  rest. 
This  murmur  is  simultaneous  with  the  dilatation  of  the 
ventricles  (Fig.  12),  and  is  produced  by  regurgitation  of 
blood  through  the  aortic  or  pulmonary  valves,  and  is 
either  an  aortic  regurgitant  or  a  pulmonic  regurgitant 
murmur. 

We  may  have,  therefore,  eight  distinct  endocardial 
murmurs,  four  systolic  and  four  diastolic.  Not  infre- 
quently we  find  in  practice  various  combinations  of 
these  different  murmurs  in  the  same  case.  For  instance, 
it  is  not  unusual  to  have  a  mitral  obstructive  and  mi- 
tral regurgitant  murmur  combined,  so  as  to  appear  to 
constitute  one  murmur  ;   the   first   sound   of  the  heart 


102 


PHYSICAL   DIAGNOSIS. 


will,  however,  enable  you  to  separate  the  two  mur- 
murs. In  like  manner,  an  aortic  obstructive  and  re- 
gurgitant murmur  are  frequently  combined ;  here  also 
the  sound  intervenes,  and  makes  the  rhythm  quite 
plain.  The  greatest  difficulty  is  when  the  normal  sound 
is  merged  into  the  murmur,  as  is  often  the  case  when 
the  mitral  obstructive   and  regurgitant  are  combined. 

The  precise  pathological   significance   of  endocardial 
murmurs  is  apparent  from  the  following  table  : 
Table  op  Cardiac  Murmurs.1 


Periods  of 
Heart's  Action. 


Seat  of  Murmur. 


Systolic. 


Left     side 
of  heart. 


Right  side 
of  heart. 


Aortic 


Mitral. 


Pulmonary. 


Tricuspid . 


Cause  of  Murmur. 
Obstruction  to  the  onward  flow 
of  blood  through  the  aortic 
orifice,  or  through  the  aorta. 

Regurgitation  of  blood  through 
the  mitral  valve  into  the  left 
auricle. 

Obstruction  to  the  onward  flow 
of  blood  through  pulmonary 
orifice,  or  through  pulmonary 
artery. 

Regurgitation  of  blood  through 
the  tricuspid  orifice  into  right 
auricle. 


Diastolic. 


Left     side 
of  heart. 


Aortic. 


Right  side 
of  heart. 


Mitral. 


Pulmonary. 


Tricuspid 


Regurgitation  of  blood  through 
the  aortic  orifice  into  left  ven- 
tricle. 

Obstruction  to  the  flow  of  blood 
from  left  auricle  to  left  ven- 
tricle. 

Regurgitation  of  blood  through 
the  pulmonary  orifice  into 
right  ventricle. 

Obstruction  to  flow  of  blood 
from  right  auricle  into  right 
ventricle. 


1  After  Fuller. 


SEAT    OF    MURMURS.  103 

Although  eight  distinct  valvular  murmurs  may  occur 
in  the  heart,  those  on  the  right  side  are  of  such  rare 
occurrence  that  they  are  of  little  clinical  importance.  If 
a  murmur  is  heard  with  the  first  sound  of  the  heart,  it 
is  almost  certainly  aortic  obstructive  or  mitral  regur- 
gitant ;  if  with  the  second  sound,  it  is  probably  aortic 
regurgitant. 

An  obstructive  mitral  murmur  is  also  of  comparatively 
rare  occurrence  :  the  force  with  which  the  blood  passes 
from  the  auricle  into  the  ventricle  is  ordinarily  insuffi- 
cient to  excite  sonorous  vibrations. 

Seat  of  Murmurs. — Having  determined  the  rhythm  of 
a  murmur,  the  next  step  in  the  investigation  is  to  find, 
within  as  narrow  Umits  as  possible,  the  place  of  its  ori- 
gin. The  points  at  which  endocardial  murmurs  are 
produced  being  in  the  majority  of  cases  one  of  the  four 
valvular  orifices,  the  first  question  to  be  settled  under 
this  head  is,  at  which  one  of  these  valvular  orifices  it  is 
produced. 

At  the  commencement  of  the  examination,  every 
means  should  be  taken  to  determine  in  each  particular 
case  the  actual  size  and  position  of  the  heart,  together 
with  its  relation  to  the  thoracic  walls  and  to  the  sur- 
rounding organs,  the  exact  point  of  the  apex  beat,  and 
the  character  of  the  impulse. 

We  must  endeavor  by  careful  stethoscopic  examina- 
tion to  determine  the  exact  seat,  and  the  limits  of  diffu- 
sion, of  the  murmur  under  observation.  If  the  murmur 
is  very  loud  or  diffused,  or  if  there  are  several  murmurs 
present  in  the  same  case,  it  may  give  rise  to  some  diffi- 
culty ;  but  in  the  large  majority  of  cases  the  observer 
will  be  able  to  fix  on  a  few  points,  or  a  few  restricted 
spaces,  over  which  each  murmur  is  heard,  there  being 


104  PHYSICAL   DIAGNOSIS. 

no  murmur  elsewhere  ;  or,  if  not  so,  areas  within  which 
each  murmur  is  heard  with  greatest  intensity. 

As  there  are  four  valvular  orifices  at  which  the  major 
ity  of  endocardial  murmurs  are  produced,  so  there  are 
four  distinct  areas  over  which  murmurs  arising  at  these 
orifices  may  be  diffused. 


Fig.  13.— Diagram  showing  the  Areas  of  Cardiac  Murmurs.  These  several  Areas  cor- 
respond to  the  Different  Spaces  marked  by  the  Dotted  Lines,  and  a  Capital  Letter  de- 
signates each  Area.  A,  the  Area  of  Mitral  Murmurs;  B,  of  Aortic  ;  C,  of  Tricuspid  ; 
and  D,  of  Pulmonic— Gairdner. 

The  following  rules  will  be  found  useful  in  recognizing 
these  areas  in  actual  practice: 

I.  Area  of  Mitral  Murmurs. — The  maximum  of  in- 
tensity of  mitral  murmurs  corresponds  generally  with 
the  apex  of  the  left  ventricle,  represented  in  Fig.  13  by 


AREA    OF   PULMONIC    MURMURS.  105 

the  circle  A.  If  it  is  produced  by  regurgitation  of  blood 
through  the  mitral  orifice,  it  is  transmitted  to  the  left 
and  backward  on  the  line  of  the  apex  beat.  The  area 
of  diffusion  in  front  corresponds  very  nearly  to  the  circle 
A,  Fig.  13,  but  it  is  heard  with  nearly  the  same  intensity 
behind,  between  the  lower  border  of  the  fifth  and  upper 
border  of  the  eighth  vertebrae,  at  the  left  of  the  spines, 
as  in  front. 

The  area  of  diffusion  of  mitral  obstructive  murmurs  is 
usually  limited  to  a  circumscribed  space  (circle  A)  around 
the  apex  of  the  heart.  In  some  instances  these  mur- 
murs are  heard  with  equal  intensity  over  the  whole  su- 
perficial cardiac  region.  To  the  left  of  the  apex  beat, 
they  are  always  indistinct,  and  are  never  heard  behind. 

II.  Area  of  Tricuspid  Murmurs. — The  area  of  tricus- 
pid murmurs  corresponds  to  that  portion  of  the  right 
ventricle  which  is  uncovered  by  lung  tissue,  indicated 
in  the  diagram  by  the  triangular  space  C.  This  murmur 
is  distinct  and  superficial  in  character,  rarely  audible 
above  the  third  rib,  and  thus  readily  distinguished  from 
the  aortic  and  pulmonic  murmurs.  It  is  heard  loudest 
near  the  xiphoid  cartilage,  and  along  the  margins  of  the 
sixth  and  seventh  costal  cartilages.  In  cases  of  hyper- 
trophy and  dilatation  of  the  right  side  of  the  heart, 
usually  its  point  of  maximum  intensity  is  at  the  junc- 
tion of  the  fourth  rib  with  the  sternum. 

III.  Area  of  Pulmonic  Murmurs. — A  murmur  in  the 
pulmonary  artery,  or  at  the  pulmonary  valves,  is  carried 
to  the  ear  nearly  over  the  seat  of  the  valves,  as  indicated 
by  the  circle  D  in  the  diagram,  Fig.  13.  Not  infrequently 
its  point  of  maximum  intensity  is  an  inch,  or  even  an 
inch  and  a  half,  lower  down.  It  is  usually  very  super- 
ficial, and  consequently  very  distinct.  It  is  limited  in 
its  diffusion,  being  inaudible  at  the  apex,  and  also  along 


106  PHYSICAL  DIAGNOSIS. 

the  sternum.  It  is  never  heard  in  the  neck,  nor  in  the 
course  of  the  great  vessels. 

IV.  Area  of  Aortic  Murmurs. — The  law  of  diffusion  of 
aortic  murmurs  is  not  easily  explained:  not  only  are  they 
heard  with  great  intensity  over  the  base  of  the  heart,  at 
the  junction  of  the  third  rib  with  the  sternum  on  the  left 
side,  but  frequently,  and  not  less  distinctly,  along  the 
whole  length  of  the  sternum,  as  is  indicated  by  the 
dotted  lines  along  the  edge  of  the  sternum,  in  the  irregu- 
lar space  B,  Fig.  13.  Sometimes  they  are  louder  close  to 
the  xiphoid  cartilage  than  at  any  other  point.  An  aortic 
murmur  is  distinguished  from  all  other  cardiac  murmurs 
by  its  propagation  into  the  arteries  of  the  neck.  It  is  the 
most  widely  diffused  of  all  cardiac  murmurs,  and  can 
sometimes  be  traced  to  a  very  great  distance  from  the 
heart.  It  may  be  heard  behind  near  the  lower  angle 
of  the  scapula. 

To  complete  the  diagnosis  of  endocardial  murmurs, 
it  is  necessary  to  consider  their  rhythm  in  connection 
with  their  area. 

First.  A  murmur  which  immediately  precedes  the 
first  sound  of  the  heart  may  be  either  a  mitral  or  tri- 
cuspid obstructive  murmur,  and  is  produced  by  obstruc- 
tion to  the  current  of  blood  as  it  passes  from  the  auricles 
into  the  ventricles.  If  it  is  a  mitral  obstructive  murmur. 
its  maximum  of  intensity  will  correspond  to  the  circle 
A,  Fig.  13  ;  if,  on  the  contrary,  it  is  a  tricuspid  obstruc- 
tive murmur,  its  maximum  of  intensity  will  be  within 
the  triangle  C. 

Second.  Murmurs  accompanying  or  following  the 
first  sound,  and  occurring  between  the  first  and  second 
sounds,  may  be  produced  either  in  the  auriculo-ventricu- 
lar  or  in  the  arterial  orifices,  and  they  have  four  distinct 
solutions. 


RHYTHM    OP   ENDOCARDIAL    MURMURS.  10? 

a.  If  it  has  its  origin  at  the  mitral  orifice,  it  is  &  mitral 
regurgitant  murmur,  and  is  produced  by  regurgitation  of 
the  blood  backward  from  the  left  ventricle  into  the  left 
auricle.  Its  maximum  of  intensity  in  front  will  corre- 
spond to  the  circle  A,  Fig.  13,  and  it  will  be  heard  behind. 

b.  If  its  origin  is  at  the  tricuspid  orifice,  it  is  a  tri- 
cuspid regurgitant  murmur,  and  is  produced  by  regurgi- 
tation of  the  blood  backward  from  the  right  ventricle 
into  the  right  auricle.  Its  maximum  of  intensity  will 
correspond  to  the  triangle  0,  Fig.  13. 

c.  If  its  origin  is  at  the  aortic  orifice,  it  is  an  aortic 
obstructive  murmur,  and  is  produced  by  obstruction  to 
the  current  of  blood  as  it  passes  from  the  left  ventricle 
into  the  aorta.  Its  maximum  of  intensity  will  corre- 
spond to  the  irregular  space  B,  Fig.  13. 

d.  If  its  origin  is  at  the  pulmonic  orifice,  it  is  a  pul- 
monic obstructive  murmur,  and  is  produced  by  obstruc- 
tion to  the  current  of  blood  as  it  passes  from  the  right 
ventricle  into  the  pulmonary  artery.  Its  maximum  of 
intensity  will  correspond  to  the  circle  D,  Fig.  13. 

Again,  murmurs  accompanying  or  following  the  sec- 
ond sound  of  the  heart  may  be  produced  at  the  aortic 
or  pulmonic  orifice,  and  in  either  case  coincide  with  the 
dilatation  of  the  ventricles. 

a.  If  the  murmur  has  its  origin  at  the  aortic  orifice,  it 
is  an  aortic  regurgitant  murmur ,  and  is  produced  by  the 
regurgitation  of  the  blood  from  the  aorta  backward  into 
the  left  ventricle.  Its  maximum  of  intensity  corre- 
sponds to  the  space  B,  Fig.  13. 

b.  If  a  murmur  following  the  second  sound  has  its 
origin  at  the  pulmonic  orifice,  it  is  a  pulmonic  regurgi- 
tant murmur,  and  is  produced  by  the  regurgitation  of 
blood  from  the  pulmonary  artery  into  the  right  ventricle.  | 


~T 


108  PHYSICAL   DIAGNOSIS. 

Its  maximum  of  intensity  corresponds  to  the  space  D, 
Fig.  13. 

One,  two,  three,  and  even  four  of  the  murmurs  we 
have  been  considering,  may  occur  in  combination  in  the 
same  case.  The  most  frequent  combinations  are  the 
aortic  obstructive  and  regurgitant,  heard  over  the  area 
B,  Fig.  13  ;  next,  the  mitral  obstructive  and  regurgitant, 
heard  over  the  area  A  ;  then  we  have  various  combina- 
tions of  these,  the  aortic  and  mitral  valves  being  both 
diseased. 

Murmurs  occurring  on  the  right  side  of  the  heart 
are  comparatively  of  rare  occurrence.  The  tricuspid 
regurgitant  is  the  only  one  that  is  of  practical  im- 
portance. 

Ancumic  and  Functional  Murmurs  are  soft  and  blowing 
in  character,  are  always  systolic,  and  almost  always 
aortic.  As  regards  their  area,  they  are  generally  dif- 
fused, not  only  over  the  base  of  the  heart,  but  along  the 
course  of  the  aorta  and  the  vessels  of  the  neck. 

An  anaemic  is  distinguished  from  an  organic  murmur 
by  its  blowing  character,  by  always  accompanying  the 
first  sound  of  the  heart,  by  being  audible  in  several  of 
the  arteries  at  the  same  time,  by  not  being  constantly 
present,  occasionally  disappearing  when  the  circulation 
is  tranquil  and  returning  when  it  is  accelerated,  by  the 
presence  of  the  general  signs  of  anaemia,  by  the  absence 
of  the  physical  or  general  signs  of  organic  disease  of  the 
heart,  by  entirely  disappearing  under  treatment  for  relief 
of  the  anaemic  state  of  the  system. 

Venous  Murmurs  all  come  under  the  class  of  inorganic 
murmurs.  The  so-called  venous  hum  is  a  continuous 
humming  sound,  having  frequently  a  musical  intonation. 
It  is  best  heard  over  the  jugular  just  above  the  clavicles, 
with  the  patient  in  a  sitting  or  standing  position.     It  is 


CAMMANN  S    RULES. 


109 


characteristic  of  anaemia,  and  is  almost  always  associ- 
ated with  an  arterial  anaemic  murmur. 

Before  leaving  the  subject  of  cardiac  murmurs,  I  will 
give  you  some  rules  in  relation  to  them,  copied  from  the 
unpublished  writings  of  the  late  Dr.  Cammann;  they  are 
the  result  of  long  and  careful  observation,  and,  although 
they  differ  in  some  respects  from  the  teachings  of  many 
auscultators,  I  have  found  them  of  great  service  in  dia- 
gnosis. 

Cardiac  Murmurs. 

AORTIC  OBSTRUCTIVE  :   SYSTOLIC. 

"  When  it  reaches  the  apex  it  is  with  diminished  in- 
tensity. 

"When  heard  behind,  it  is  most  distinct  at  left  of 
third  and  fourth  vertebrae,  close  to  their  spines,  and  fre- 
quently extends  downward  along  the  spine  in  the  course 
of  the  aorta,  but  with  diminished  intensity.  Although 
the  heart  only  extends  as  high  as  the  fifth  vertebra,  the 
murmur  is  heard  above  that  point,  because  here  the 
aorta  approaches  the  surface. 

AORTIC  REGURGITANT  :   DIASTOLIC. 

"  The  intensity  of  the  murmur  from  valve  to  right  of 
apex  may  or  may  not  increase  downward,  depending  on 
the  proximity  of  heart  to  parietes,  the  position  of  lungs, 
etc. ;  it  may  decrease  downward,  however,  from  emphy- 
sema, supine  recumbency,  etc.,  or  may  perchance  be 
loudest  at  apex,  depending  on  proximity  of  heart  to  the 
parietes,  position  of  the  parts,  condition  of  the  mitral 
valve,  etc. 

"  Generally  it  is  not  heard  behind,  but  may,  toward 
inner  side  of  lower  angle  of  scapula,  in   thin  subjects 


110  PHYSICAL  DIAGNOSIS. 

especially,  be  heard  in  the  same  place  where  is  heard  the 
non-mitral  regurgitant ;  this  non-mitral  regurgitant  be- 
ing the  mitral  regurgitant  of  Bellingham  and  others. 

"  It  is  sometimes  conveyed  to  left  axilla. 

"  The  patient  when  recumbent  may  sometimes  hear  it 
himself. 

MITRAL   REGURGITANT  :    SYSTOLIC. 

"  To  indicate  regurgitation,  the  murmur  must  be  heard 
between  lower  border  of  fifth  and  upper  border  of  eighth 
vertebra,  at  left  of  spine,  provided  the  transmission  of 
the  sound  be  not  interfered  with  by  thickness  of  integu- 
ments, or  other  conditions  of  the  parts. 

"When  not  heard  in  this  place,  but  in  'left  axilla 
and  in  the  region  of  the  left  scapula,'  regurgitation  is 
not  indicated  ;  or,  in  other  words,  it  is  a  non-regurgitant 
murmur,  contrary  to  the  teaching  of  Bellingham  and 
others. 

"If  there  be  a  systolic  murmur  with  a  maximum  of 
intensity  between  fifth  and  eighth  vertebrae,  at  left  of 
spine,  it  indicates  regurgitation. 

"An  aneurismal  murmur,  however,  may  be  heard 
within  the  said  limits,  but  it  follows  the  aorta  down- 
ward, gradually  decreasing  in  intensity,  without  the 
abrupt  termination  of  the  regurgitant  murmur. 

"We  occasionally  meet  with  mitral  regurgitant  mur- 
mur posteriorly,  yet  absent  anteriorly. 

"  The  mitral  regurgitant  murmur  may  sometimes  cease 
entirely,  from  such  a  change  in  the  structural  condition 
of  the  diseased  valve,  or  from  such  contraction  of  the 
auriculo-ventricular  opening,  as  will  allow  the  valve  to 
close  so  as  to  prevent  regurgitation,  there  being  actually 
in  this  case  increased  mechanical  obstruction. 

"The  following  complication  may  exist,  viz.,   aortic 


VARIOUS    HEART    SOUNDS.  Ill 

obstructive  systolic,  with  aortic  regurgitant  diastolic  ex- 
tending to  the  apex,  with  the  mitral  regurgitant  behind, 
without  a  corresponding  murmur  in  front. 

"All  these  murmurs  are  not  infrequently  heard  to 
right  of  apex,  and  even  over  the  whole  chest. 

"  A  mitral  diastolic  murmur  we  have  not  heard.  If 
ever  present,  as  stated  by  distinguished  auscultators,  it 
must  depend  upon  physical  condition  external  to  the 
heart.  Thus,  pleuritic  effusions  or  the  like,  in  certain 
positions,  by  pressing  suddenly  and  strongly  upon  the 
left  auricle,  may  possibly  force  the  blood  with  sufficient 
rapidity  through  an  obstructed  auriculowentricular  ori- 
fice to  cause  an  abnormal  sound. 

"  Some  auscultators,  however,  deny  the  possibility  of 
the  occurrence  of  this  murmur  under  any  contingency 
whatever. " 

Ventricular  Murmurs. 

Not  infrequently  during  the  active  progress  of  endo- 
carditis, as  well  as  after  the  acute  stage  is  passed,  a  mur- 
mur is  heard  taking  the  place  of,  or  following,  the  first 
sound  of  the  heart.  These  murmurs  are  not  conveyed  to 
the  left  of  the  apex,  nor  heard  along  the  course  of  the 
aorta.  They  are  undoubtedly  produced  within  the  cav- 
ity of  the  left  ventricle,  either  by  the  roughening  of  the 
chordae  tendinese  or  the  ventricular  surface  of  the  mitral 
valves,  or  perhaps  by  an  abnormal  direction  to  the  cur- 
rent of  blood  as  it  passes  through  the  ventricle.  They 
may  properly  be  called  ventricular  murmurs,  and  may  be 
distinguished  from  other  murmurs  by  the  time  of  their 
occurrence  and  by  their  limited  area  of  diffusion. 

Sounds  produced  by  the  Action  of  the  Heart  ivhich 

are  neither  Endocardial  nor  Pericardial. 
Sounds  sometimes  are  heard  in  the  precordial  region, 


112  PHYSICAL    DIAGNOSIS. 

produced  by  the  action  of  the  heart  on  the  lungs.  These 
sounds  are  mostly  systolic  and  inspiratory:  they  usually 
cease  when  the  respiratory  movements  are  arrested.  A 
blowing  sound  resembling  a  cardiac  murmur  may  be 
produced  in  the  lung  tissue  covering  the  heart,  during  a 
cardiac  systole.  A  pulmonary  cavity  near  enough  to  the 
heart  to  be  influenced  by  it  sometimes  affords  a  loud 
systolic  murmur.  Sounds  resembling  rales  may  be  pro- 
duced by  the  movements  of  the  heart  upon  the  bronchial 
tubes.  Friction  sounds  generated  in  the  pleura,  of  a 
crackling,  rasping  character,  synchronous  with  the  car- 
diac systole,  are  not  infrequently  heard.  A  friction 
sound  heard  behind  and  along  the  edge  of  the  sternum 
from  the  second  to  the  sixth  rib  is  always  pericardial; 
but  when  a  friction  sound  is  heard  at  other  parts  of  the 
precordia,  the  diagnosis  is  often  difficult.  Pleuritic  fric- 
tion sound  usually  ceases  when  the  breath  is  held,  but 
this  is  not  always  the  case. 


LESSOR  XII. 

SYNOPSIS    OF     THE     PHYSICAL     SIGNS      OF     PERICARDITIS — 
HYPERTROPHY,    DILATATION,    AND    FATTY  DEGENE- 
RATION   OF    HEART,    AND     ANEURISMS 
OF   THORACIC   AORTA. 

Synopsis  of  the  Physical  Signs  of  Pericarditis. 

The  physical  signs  of  pericarditis  vary  with  the  dif- 
ferent stages  of  the  disease.  In  the  early  period  of  the 
attack,  the  only  sign  furnished  by  inspection  and  palpa- 
tion is  an  irritable  and  forcible  action  of  the  heart,  and 
there  is  no  change  in  the  area  of  the  precordial  dulness 
on  percussion.  For  some  time  the  only  characteristic 
sign  of  its  presence  is  the  pericardial  friction  sound. 
After  a  time,  as  the  inflammation  progresses,  effusions 
take  place  into  the  pericardial  sac,  and  we  have  the  sec- 
ond stage,  or  stage  of  effusion. 

Inspection  now  discloses  a  prominence,  or  arching  for- 
ward, of  the  precordial  region,  and  a  diminution  in  the 
respiratory  movements  of  the  left  side. 

Palpation  shows  the  point  of  the  apex  beat  to  be 
raised  and  carried  to  the  left  of  its  normal  position  ;  or, 
if  the  quantity  of  the  effusion  be  large,  it  is  entirely 
suppressed.  Sometimes,  in  extensive  pericardial  effu- 
sions, an  undulatory  impulse  is  felt.  The  position  of 
the  impulse  will  often  be  noticed  to  change  with  a 
change  in  the  position  of  the  patient.  If  the  cardiac 
impulse  is   entirely  absent   when  the  patient  is  in  the 

8 


114 


PHYSICAL   DIAGNOSIS. 


recumbent  posture,  and  becomes  perceptible  when  he  is 
placed  in  a  sitting  posture,  you  have  strong  presumptive 
evidence  in  favor  of  pericardial  effusion.  Sometimes 
when  the  pericardium  is  very  greatly  distended,  the  dia- 
phragm is  depressed,  and  bulging  can  be  detected  in  the 
epigastrium. 

Percussion. — The    area  of  the  precordial  dulness  is 
enlarged  vertically  and  laterally.     At  the  beginning,  the 


Fig.  14.— Diagram  showing  the  Pericardial  Sac  partially  filled  with  Liquid,  and  Plas- 
tic Exudation  upon  the  two  Surfaces  of  the  Pericardium  above  the  level  of  the  Liquid. 

dulness  is  principally  increased  upward,  but  any  con- 
siderable amount  of  effusion  is  denoted  by  an  increase 
in  the  width  of  the  area  of  dulness  at  the  lower  portion 
of  the  precordial  region.  As  the  effusion  increases,  the 
shape  of  the  enlarged  area  corresponds  to  the  pyramidal 
form  of  the  pericardial  sac,  as  is  represented  in  Fig.  14. 

When  the  pericardial  sac  is  distended  with  liquid,  the 
dulness  will  reach  as  high  as  the  first  rib  :    not  infre- 


PHYSICAL    SIGN'S    OF    CARDIAC    HYPERTROPHY.  115 

quently  it  reaches  an  inch  or  more  to  the  right  of  the 
sternum,  and  occasionally  it  extends  from  nipple  to 
nipple. 

Auscultation. — The  friction  soand  of  the  plastic  stage 
becomes  more  and  more  indistinct  until  it  ceases  alto- 
gether. The  heart  sounds  become  feeble  or  are  entirely 
lost,  and  the  respiratory  murmur  and  the  vocal  reso- 
nance are  absent  over  the  area  of  precordial  dulness. 

AVhen  recovery  takes  place  and  the  liquid  effusion  is 
absorbed,  the  bulging  of  the  precordial  region,  which 
was  present  in  the  stage  of  effusion,  subsides,  and  the 
area  of  dulness  on  percussion  decreases,  the  friction 
sound  reappears,  the  heart  sounds  become  distinct,  the 
apex  beat  resumes  its  normal  position,  the  impulse  re- 
gains its  natural  force,  and  the  respiratory  and  vocal 
sounds  are  again  heard  over  the  space  formerly  occu- 
pied by  the  distended  pericardium. 

Adhesion  of  the  heart  to  the  pericardium  does  not  ad- 
mit of  diagnosis,  unless  firm  adhesions  have  formed  be- 
tween the  external  surface  of  the  pericardium  and  the 
adjacent  tissues,  which  afterward  cause  dilatation  and 
hypertrophy  of  the  heart,  accompanied  by  recession 
of  the  apex  beat,  retraction  of  the  epigastrium,  and 
diminished  motion  of  the  pericardial  portion  of  the 
diaphragm  during  a  full  inspiration. 

Synopsis  of  the  Physical  Signs  of  Cardiac 
Hypertrophy. 

The  physical  signs  of  hypertrophy  of  the  heart  vary 
with  the  seat  and  extent  of  the  hypertrophy.  "When 
the  hypertrophy  is  general,  inspection  shows  the  action 
of  the  heart  to  be  regular,  and  the  visible  impulse  to  be 
increased  in  extent  and  in  force.  In  children  there  is  a 
visible  prominence  of  the  precordial  region. 


116  PHYSICAL   DIAGNOSIS. 

Palpation. — The  area  greatly  exceeds  that  within 
which  the  normal  apex  beat  is  felt,  and  the  impulse  has 
a  heaving,  lifting  character.  When  the  right  ventricle 
is  hypertrophied,  the  conducted  epigastric  impulse  is 
strong.  When  the  left  ventricle  is  hypertrophied,  the 
apex  beat  reaches  further  to  the  left  than  natural,  some- 
times three  inches  below  and  three  or  four  inches  to  the 
left  of  the  normal  position. 


Fig.  13.— Hypertrophy  of  Left  Ventr  cle.  Heart  in  situ,  a,  the  Mammary  Line. 
6,  Vena  Cava  Superior,  c,  Aorta,  d,  Pulmonary  Artery,  e,  Bight  Auricle.  /,  Right 
Ventricle,  g,  Left  Auricle,  h,  Left  Ventricle  (normal  outline),  o,  Hypertrophied 
Ventricle.— Rindfleisch. 

Percussion. — The  area  of  both  the  superficial  and 
deep-seated  dulness  increases  laterally  and  downward. 
If  the  hypertrophy  is  confined  to  the  left  ventricle,  the 
area  of  dulness  on  percussion  may  extend  beyond  the 
left  nipple,  as  is  shown  in  Fig.  15. 

If,  on  the  other  hand,  the  hypertrophy  is  confined 
to  the  right  ventricle,  the  area  of  dulness  may  extend 


CARDIAC    HYPERTROPHY".  II? 

considerably  to  the  right  of  the  sternum,  as  is  shown  in 
Fig.  16. 

Auscultation. — The  first  sound  is  dull,  muffled,  and 
prolonged,  and  in  some  cases  greatly  increased  in  in- 
tensity. The  second  sound  is  also  increased  in  intensity 
and  more  diffused  than  in  health,  and  there  is  a  dimi- 
nution or  an  entire  absence  of  the  respiratory  murmur 
over  the  normal  precordial  region . 


,'  K   N- 


V-V-  j  % ' 

Fig.  J.6.— Hypertrophy  of  Right  Ventrcle.    Heart  in  situ.    Description  as  in  the  pre- 
ceding figure.    The  contour  of  the  Hypertrophied  Right  Ventricle   is   indicated  by 

dOtS.— RlNDFLEISCH. 

When  hypertrophy  of  the  walls  of  the  heart  is  at- 
tended with  extensive  dilatation  of  its  cavities,  the 
action  of  the  heart  is  still  regular,  but  the  extent  of  the 
visible  impulse  is  greatly  increased,  extending  sometimes 
from  the  third  intercostal  space  to  the  epigastrium.  The 
apex  beat  may  be  felt  as  low  as  the  ninth  rib,  and  to 
the  left  of  the  nipple,  and  has  a  peculiar  heaving 
character,  so  as  sometimes  to  shake  the  bed  of  the 
patient. 


118  PHYSICAL  DIAGNOSIS. 

The  area  of  dulness  may  extend  vertically  from  the 
third  to  the  eighth  rib,  and,  laterally,  an  inch  to  the 
right  of  the  sternum  and  two  or  three  inches  to  the  left 
of  the  left  nipple.  Both  sounds  of  the  heart  are  pro- 
longed, and  are  often  audible  over  the  whole  chest,  even 
to  the  right  of  the  spine. 

Dilatation  of  the  Heart. 

Inspection. — The  visible  area  of  the  apex  beat  is 
greatly  increased,  but  it  is  difficult  to  determine  its 
point  of  maximum  intensity.  Sometimes  there  is  an 
undulating  motion  over  the  whole  precordial  space. 

Palpation. — By  palpation  you  readily  distinguish  di- 
latation from  hypertrophy  by  the  feebleness  of  the  car- 
diac impulse  ;  and  although  it  sometimes  can  be  felt  as 
far  to  the  left  as  the  axillary  line,  there  is  an  entire  ab- 
sence of  the  lifting,  forcible  impulse  which  attends  car- 
diac hypertrophy.  Sometimes  a  purring  thrill  attends 
cardiac  dilatation,  especially  when  mitral  regurgitation 
is  present. 

Percussion  shows  a  lateral  increase  in  the  area  of  pre- 
cordial dulness  ;  to  the  right  when  the  right  cavities  are 
involved,  and  to  the  left  when  the  left  cavities  are  di- 
lated. The  shape  of  the  dull  space  remains  oval.  This 
point  is  of  importance  in  the  diagnosis  between  cardiac 
dilatation  and  pericardial  effusion. 

Auscultation. — The  sounds  of  a  dilated  heart  are  al- 
ways short,  abrupt,  and  feeble.  The  second  sound  is 
often  inaudible  at  the  apex,  and  the  two  sounds  seem 
to  be  of  equal  duration.  If  endocardial  murmurs  have 
been  present,  as  the  dilatation  becomes  extreme,  no- 
thing is  heard  but  a  kind  of  swimming  sound.  The 
respiratory  murmur  is  often  feeble  over  the  whole  of 
the  upper  portion  of  the  left  lung. 


FIBROID    HEART.  119 

Asystolism. 

Asystolism  is  a  term  ' '  employed  to  designate  that  re- 
markable group  of  symptoms  which  is  characteristic  of 
an  enduring  inability  in  the  right  ventricle  to  empty  it- 
self.'" '  The  physical  signs  are  those  of  dilatation  of  the 
right  side  of  the  heart.  A  short  time  before  death  addi- 
tional signs  occur,  viz.  :  On  palpation  the  cardiac  im- 
pulse is  feeble ;  on  auscultation  the  heart  sounds,  or  any 
endocardial  murmurs  which  may  have  been  present,  be- 
come gradually  more  and  more  feeble,  until  nothing 
is  heard  except  a  humming  sound.  A  tricuspid  regur- 
gitant murmur  frequently  develops  when  asystolism  be- 
comes urgent,  but  before  the  heart  is  so  weakened  that 
it  is  not  able  to  produce  a  murmur.  If  the  symptoms 
of  asystolism  are  moderate,  the  murmur  disappears. 

Fatty  Heart. 

The  physical  signs  of  fatty  degeneration  of  the  heart 
in  many  respects  are  identical  with  those  of  cardiac  di- 
latation. The  area  of  the  precordial  dulness  is  normal, 
the  impulse  weak  or  imperceptible,  the  apex  beat  indis- 
tinct and  often  invisible.  The  action  of  the  heart  is 
irregular,  the  first  sound  is  short  and  feeble  and  some- 
times inaudible,  the  second  sound  prolonged  and  inten- 
sified. 

Fibroid  Heart. 

The  physical  signs  of  cardiac  fibrosis  are  feeble,  rapid, 
irregular,  intermittent  heart  action ;  a  diffused,  feeble 
cardiac  impulse  ;  weak  but  sharp  heart  sounds.  The 
first  sound  is  like  the  second  in  tone  and  duration. 
They  closely  resemble  the  foetal  heart  sounds.     On  per- 

1  Beau,  "Considerations  generates  sur  les  Maladies  du  Coeur," 
Arch.  Gen.  de  Med.,  1853. 


120  PHYSICAL  DIAGNOSIS. 

cussion  we  find  the  area  of  dulness  increased,  chiefly  to 
the  left.  The  diagnosis  of  a  fibroid  heart  cannot  be 
made  by  the  physical  signs  alone  ;  we  must  take  them 
in  connection  with  the  symptoms  and  condition  of  the 
arterial  system.  By  the  physical  signs  we  determine 
that  the  heart  is  chronically  weak.  If,  then,  we  find 
evidence  of  a  weak  heart  in  one  who  has  a  strong 
fibroid  history,  and  who  gives  signs  of  a  general  arte- 
rial fibrosis,  the  diagnosis  is  readily  made. 


LESSCOT  XIII. 

ANEUEISM   OF   THE   THORACIC   AORTA  AND   ARTERIA 

INNOMINATA— EPIGASTRIC    PULSATION— 

SUB-CLAVIAN  MURMURS — VENOUS 

PULSATIONS   AND   MURMURS. 

Aneurisms  of  the  Thoracic  Aorta.— The  thoracic 
aorta  is  affected  by  aneurism  with  varying  degrees  of 
frequency  in  the  different  parts  of  its  course.  Accord- 
ing to  Sibson,  who  has  collected  the  statistics  of  703 
cases,  87  were  at  the  commencement  of  the  aorta  in  the 
sinuses  of  Valsalva ;  193  of  the  ascending  arch,  extra- 
pericardial;  14  of  the  ascending  and  transverse  arch ; 
12  of  the  transverse  arch ;  72  of  the  descending  arch ; 
and  71  of  the  descending  aorta 

The  physical  methods  employed  in  ascertaining  the 
existence  of  aneurisms  are  inspection,  palpation,  per- 
cussion, and  auscultation. 

Inspection. — If  the  aneurism  presses  on  the  superior 
vena  cava,  you  will  find  the  face,  neck,  and  upper 
extremities  swollen,  livid,  and  occasionally  cedematous, 
and  the  large  veins  of  these  regions  turgid  and  vari- 
cose. But  if  the  pressure  is  on  an  innominate  vein, 
these  effects  will  be  observed  only  on  the  corresponding 
side. 

In  some  instances  there  is  a  thick,  fleshy  collar  sur- 
rounding the  lower  part  of  the  neck,  due  to  capillary 
turgescence.     As  you  inspect  the  chest,  a  more  or  less 


122  PHYSICAL   DIAGNOSIS. 

extensive  bulging  may  be  observed  at  some  point  along 
the  course  of  the  aorta.  The  bulging  may  in  some  cases 
attain  the  size  of  a  cocoanut,  while  in  others  it  may  be 
perceptible  only  on  close  examination.  The  non-exist- 
ence of  a  tumor  does  not,  however,  prove  that  there  is 
no  aneurism,  for  if  the  aneurismal  enlargement  springs 
from  the  posterior  wall  of  the  arch,  or  from  the  descend- 
ing arch  or  descending  aorta,  parts  which  are  deeply 
seated,  there  may  be  no  visible  anterior  bulging. 

When  the  bulging  portion  is  of  large  size,  it  is  gene- 
rally conical  in  shape,  the  surface  is  smooth,  and  the 
skin  looks  tense  and  glazed.  In  most  cases  you  will 
observe  a  pulsation  of  the  tumor  synchronous  with  the 
heart's  systole;  where  this  occurs  in  the  anterior  portion 
of  the  chest,  there  seem  to  be  two  beats  within  the 
thorax  at  the  same  time.  Sometimes  you  can  only  de- 
tect the  pulsation  by  bringing  the  eye  to  a  level  with, 
and  looking  across,  the  chest.  If  the  aneurism  is  full  of 
fibrin,  there  may  be  no  visible  pulsation. 

The  position  of  the  bulging  affords  a  clue  to  the  seat 
of  the  aneurism.  Aneurism  of  the  ascending  arch  pro- 
duces bulging  to  the  right  of  the  sternum,  near  the  sec- 
ond costal  cartilage;  though  when  large  it  may  extend 
into  both  mammary  and  infra-clavicular  regions.  Aneu- 
rism of  the  transverse  arch  causes  protrusion  of  the 
upper  part  of  the  sternum.  Aneurism  of  the  descending 
arch  protrudes  to  the  left  side  of  the  sternum,  though 
often,  from  the  deep  position  of  the  artery  in  this  part 
of  its  course,  no  tumor  may  be  felt.  Aneurism  of  the 
descending  aorta  shows  itself  on  the  left  side  of  the 
spine,  very  rarely  on  the  right. 

Palpation. — By  the  application  of  the  hand  you  can 
appreciate  better  the  size  of  the  tumor,  the  nature  of  its 
contents  (whether  mostly  liquid  or  solid),  the  condition 


ANEURISMS  OF  THE  THORACIC  AORTA.        123 

of  the  walls  as  regards  perforation  of  the  sternum  or 
ribs,  and  the  character  of  the  pulsation,  which  is  usually 
that  of  a  blow  equally  diffused  in  all  directions.  Besides 
the  systolic  impulse,  a  diastolic  one  sometimes  occurs; 
generally  it  is  slight,  sometimes,  however,  it  is  quite 
forcible.  In  some  cases  you  will  obtain  the  impulse  by 
pressing  with  one  hand  on  the  sternum,  and  the  other 
on  the  back,  when  by  ordinary  palpation  you  would  not 
detect  it.  Again,  if  the  aneurism  is  at  the  upper  portion 
of  the  arch,  by  pressing  the  fingers  down  behind  the 
sternum  a  distinct  impulse  will  be  felt.  You  may  also 
ascertain  by  palpation  whether  there  is  a  cessation  or 
diminution  of  the  expansive  movement  over  the  whole 
or  part  of  one  lung,  and  whether  the  vocal  fremitus  is 
lost  over  that  side  and  over  the  tumor. 

The  non-expansion  and  loss  of  vocal  fremitus  over 
the  lung  is  due  generally  to  the  pressure  of  the  aneurism 
on  the  air  passages,  or  on  the  lung  itself.  When  the 
aneurism  presses  on  the  carotid  arteries,  or  when  they 
are  obstructed  by  coagula,  a  difference  between  the 
pulse  of  these  arteries  and  their  branches  on  the  two 
sides  will  be  noticed. 

Percussion. — There  will  be  dulness  over  the  promi- 
nence, or  over  a  circumscribed  space,  in  the  neighbor- 
hood of  the  course  of  the  aorta,  not,  however,  corre- 
sponding to  the  size  of  the  aneurism,  unless  more 
forcible  percussion  be  made  than  is  safe.  The  resist- 
ance is  increased  in  proportion  to  the  amount  of  the 
fibrin  in  the  sac.  When  the  lung  is  condensed  by 
inflammation,  or  collapsed  by  obstruction  of  the  bron- 
chus, there  will  be  a  greater  area  of  dulness. 

Auscultation. — There  are  usually  certain  sounds  or 
murmurs  connected  with  an  aneurism.  In  some  cases 
neither  are  audible,  owing  either  to  the  position  of  the 


124  PHYSICAL    DIAGNOSIS. 

aneurism,  to  the  solidity  of  its  contents,  or  to  the  na- 
ture of  its  orifice.  These  sounds  resemble  those  of  the 
heart.  aDd  are  similarly  called  systolic  and  diastolic  ; 
they  may  be  either  equal  to,  or  weaker,  or  louder  than, 
those  of  the  heart  ;  the  systolic  may  exist  alone  ;  either 
or  both  sounds  may  be  replaced  by  a  murmur — for  in- 
stance, there  may  be  a  systolic  murmur  only,  or  you 
may  have  both  a  systolic  and  a  diastolic  sound.  The 
character  of  the  murmur  varies.  It  is  usually  short, 
abrupt,  of  low  pitch,  and  as  loud  or  louder  than  the 
loudest  heart  murmur.  It  may  be  rasping,  sawing, 
filing,  etc.  The  diastolic  murmur  is  rarer  than  the  sys- 
tolic, and  is  usually  of  a  softer  quality.  Where  the 
aneurism  compresses  a  large  bronchus,  the  respiratory 
murmur  over  the  whole  or  a  part  of  one  side  will  be 
weak  or  suppressed  ;  on  the  opposite  side  it  will  be  ex- 
aggerated. There  is  also  loss  of  vocal  resonance  over 
the  aneurism,  and  over  the  lung  whose  bronchus  is 
obstructed.  Where  the  lung  is  condensed  from  pres- 
sure, the  breathing  will  be  bronchial ;  where  there  is 
pressure  over  the  trachea  or  bronchi,  the  breathing  may 
be  stridulous,  and  be  rightly  referred  to  a  lower  point  of 
production  than  the  larynx.  Where  there  is  irritation 
of  the  recurrent  laryngeal  nerve,  this  type  of  breathing 
may  come  from  spasm  of  the  glottis. 

Differential  Diagnosis. — You  will  find  that  the  prin- 
cipal difficulties  in  diagnosis  are  between  aneurisms  and 
intra-thoracic  tumors. 

The  latter  are  rare.  They  rarely  pulsate,  or,  if  they 
should,  they  will  communicate  to  the  hand  a  mere  lift- 
ing pulsation  ;  in  some  instances  malignant  tumors 
have,  however,  a  true  expansive  impulse.  Again,  in- 
tra-thoracic tumors  are  not  usually  developed  entirely  in 
the  track  of  the  aorta.     Their  area  of  dulness  is  large, 


EPIGASTRIC   PULSATION.  125 

and  the  resistance  communicated  to  the  finger  on  per- 
cussion is  usually  great.  As  a  rule,  there  are  no  sounds 
or  murmurs  connected  with  them,  though  in  some  cases 
where  a  tumor  is  placed  over  the  aorta  a  murmur  may 
occur.  Tumors  are  more  apt  to  produce  persistent 
swelling  and  oedema  of  the  upper  extremities,  neck, 
and  face.  In  a  case  of  aneurism,  this  latter  sign  may 
develop,  and  then  disappear  owing  to  a  change  in  the 
direction  of  the  pressure.  Tubercular  consolidation  of 
one  apex,  if  associated  with  a  murmur  in  the  sub- 
clavian or  pulmonary  artery,  might  be  mistaken  for  an 
aneurism.  In  the  former  we  have  the  physical  signs  of 
tuberculosis.  The  murmur  is  heard  in  the  course  of  the 
pulmonary  or  sub-clavian  artery.  The  dulness  is  not 
circumscribed,  and  extends  outward,  and  not  across 
the  median  line. 

Pulsatile  Empyema,  it  seems  to  me,  could  hardly  be 
mistaken  for  aneurism,  although  such  instances  are  on 
record,  for  it  does  not  occupy  the  position  of  an  aneu- 
rism. Then  you  have  the  physical  signs  of  effusion  into 
the  pleural  sac,  and  it  is  attended  by  no  sounds  or 
murmurs. 

Aneurism  of  the  Arteria  Innominata  is  distin- 
guished from  aneurism  of  the  thoracic  aorta  by  the 
fact  that  the  tumor  appears  early  on  the  right  of  the 
sternum.  As  it  increases,  it  pushes  forward  the  inner 
part  of  the  clavicle,  or  extends  upward  into  the  neck. 
Its  pulsation  is  diminished  or  suspended  by  pressure  on 
the  carotid  or  sub-clavian  artery,  while  an  aneurism  of 
the  aorta  will  not  be  affected  by  such  pressure. 

Epigastric  Pulsation  may  be  produced  by  an  aneu- 
rism of  the  abdominal  aorta  involving  th.3  c celiac  axis, 
by  tumors  seated  on  the  abdominal  aorta,  by  displace- 
ment of  the  heart  to  the  right,  by  regurgitation  of  blood 


120  PHYSICAL   DIAGNOSIS. 

into  the  hepatic  veins  consequent  upon  dilatation  of 
the  right  side  of  the  heart,  and  by  pulsation  of  the  ab- 
dominal aorta. 

Not  infrequently  the  impulse  of  the  apex  beat,  the 
heart  being  normal  and  in  its  normal  position,  is  com- 
municated to  the  epigastrium,  and  is  mistaken  for  epi- 
gastric pulsation  of  a  dilated  heart. 

The  right  ventricle,  in  such  cases,  will  usually  be 
found  lower  than  its  normal  position,  and  may  even 
beat  against  the  xiphoid  cartilage. 

Sub-cl avian  Murmurs. — Not  infrequently  just  below 
the  clavicles,  especially  on  the  left  side,  a  systolic  mur- 
mur is  heard  directly  over  or  along  the  course  of  the 
sub-clavian  artery.  These  murmurs  resemble  those 
produced  by  pressure  on  arteries.  It  is  reasonable, 
therefore,  to  infer  that  they  are  produced  in  the  same 
way — the  exact  anatomical  condition,  however,  which 
causes  them  is  still  unsettled.  Adhesions  at  the  apex  of 
the  lung  have  been  suggested,  also  pressure  from  pul- 
monary consolidation  at  the  apex.  One  thing  is  cer- 
tain, that  they  are  more  frequently  met  with  in  those 
persons  who  are  tubercular  than  in  others.  They  are 
often  most  intense  during  expiration. 

I  have  known  the  presence  of  a  sub-clavian  murmur 
to  be  taken  as  an  evidence  of  aneurism. 

Veins. — A  state  of  permanent  turgescence  or  disten- 
tion of  the  jugular  veins,  as  well  as  of  the  superficial 
veins  of  the  upper  part  of  the  chest  and  neck,  with  or 
without  pulsation,  is  frequently  met  with  in  the  ad- 
vanced stage  of  many  forms  of  cardiac  disease,  in  tho- 
racic aneurism,  and  in  any  change  in  the  thoracic  organs 
which  causes  obstruction  to  the  free  passage  of  blood 
through  the  right  side  of  the  heart.. 

Permanent  turgescence  of  the  jugular  veins  is  usually 


VENOUS   MURMURS.  127 

due  to  the  distention  of  the  right  auricle  ;  any  obstruc- 
tion, however,  to  the  superior  vena  cava  or  innominata, 
such  as  compression,  thrombosis,  or  stricture,  will  have 
the  same  effect.  If  the  turgescence  is  temporary,  a  full 
inspiration  will  empty  and  collapse  the  distended  veins, 
while  a  full  expiration  will  increase  their  distention. 
On  the  other  hand,  if  the  turgescence  is  permanent,  the 
condition  of  the  veins  is  not  affected  by  the  respiratory- 
acts. 

Venous  Pulsations  may  be  presystolic  or  systolic. 
They  are  most  marked  in  the  jugular  veins  immediately 
above  the  clavicles. 

Presystolic  jugular  pulsations  are  due  to  the  contrac- 
tions of  the  right  auricle,  but  they  can  seldom  be  appre- 
ciated except  when  the  intra-thoracic  veins  are  distended. 
Sometimes  in  a  perfectly  healthy  person,  when  in  a 
recumbent  position,  presystolic  pulsation  in  the  jugular 
veins  can  be  seen. 

Systolic  jugular  pulsation  occurs  with  the  systole  of 
the  ventricles  and  indicates  regurgitation  into  the  right 
auricle  with  the  ventricular  systole.  Friedreich  states 
that  sudden  collapse  of  the  jugular  veins  occurs  in  some 
cases  of  pericardial  adhesions.  Pulsations  in  the  carotid 
arteries  often  communicate  systolic  pulsations  to  the 
jugulars. 

Venous  Murmurs. — In  auscultating  the  veins  of  the 
neck,  besides  the  venous  hum  already  referred  to  in 
Lesson  XII.,  presystolic,  systolic,  and  diastolic  murmurs 
are  sometimes  heard  over  the  jugulars. 

Presystolic  venous  murmurs  are  only  heard  when  the 
patient  is  in  the  recumbent  posture,  and  are  due  to  the 
passage  of  blood  backward  through  the  mouth  of  the 
internal  jugular. 

Systolic  venous  murmurs   are   sometimes  heard   just 


128  PHYSICAL   DIAGNOSIS. 

above  the  clavicles,  especially  on  the  right  side,  in  cases 
of  tricuspid  regurgitation. 

Diastolic  venous  murmurs  are  only  occasionally  heard, 
and  require  for  their  production  cardiac  hypertrophy  and 
dilatation  with  aneurism. 


ABDOMEN 


LESSOR    XIV. 

INTRODUCTION — TOPOGRAPHY       OF       THE      ABDOMEN — CON- 
TENTS    OF     THE     VARIOUS     REGIONS — ABDOMINAL 
INSPECTION,     PALPATION,     PERCUSSION, 
AND  AUSCULTATION — DISEASED  CON- 
DITIONS OF  THE  PERITONEUM. 

There  are  difficulties  in  the  physical  exploration  of 
the  abdomen  which  are  not  met  with  in  similar  exami- 
nations of  the  thorax. 

First.  Thoracic  diseases  involve  in  their  diagnosis  the 
examination  of  only  one  or  two  organs,  or  their  cov- 
erings, while  an  abdominal  affection  may  require  for 
its  diagnosis  the  examination  of  ten  or  twelve  organs. 
Thus  a  tumor  in  the  left  side  may  be  either  an  enlarged 
mesenteric  gland,  or  it  may  be  connected  with  the  stom- 
ach, spleen,  kidneys,  ovaries,  or  uterus  ;  or  it  may  be  a 
hernia,  an  abscess,  an  hydatid  cyst,  an  aneurism,  or, 
lastly,  only  a  lump  of  faeces. 

Second.  The  action  of  the  thoracic  organs  is  regular 
and  rhythmical,  and  their  contents  unvarying,  while  the 
action  of  the  abdominal  viscera  is  often  irregular  and  in- 
termittent. An  abdominal  organ  may  also  at  one  time 
be  greatly  distended  and  soon  after  be  empty ;  when 
filled,  its  contents  may  be  solid,  liquid,  or  gaseous,  or  all 
these  together.  The  lungs  and  heart  contain  respec- 
tively the  same  quantities  of  air  and  blood  during  every 
five  minutes  of  ordinary  life,  but  the  stomach  and  blad- 
der can  never  remain  long  in  one  condition,  either  full 
or  empty. 


132  PHYSICAL   DIAGNOSIS. 

Third.  The  abdominal  organs  are  packed  loosely  in  a 
cavity  with  loose  walls.  They  therefore  can  be  increased 
or  decreased  in  size,  so  as  to  alter  wholly  their  relations 
to  their  fellow-organs.  Thus  the  uterus,  usually  the 
smallest,  will,  in  fulfilling  its  natural  function,  become 
much  the  largest  of  all,  crowding  even  the  thoracic 
organs.  In  disease,  a  single  ovary  may  swell  into  a  sac 
which  will  fill  entirely  the  abdominal  cavity.  These 
constitute  the  chief  difficulties  in  the  physical  exami- 
nation of  the  abdomen,  and  they  must  always  throw  a 
certain  degree  of  doubt  upon  all  physical  diagnoses  di- 
rected to  this  part  of  the  body. 

To  facilitate  our  examinations,  and  to  render  our  in- 
ferences more  certain,  it  is  well  to  divide  the  abdomen 
into  regions  by  passing  imaginary  planes  through  the 
body. 

The  divisions  which  have  been  proposed  by  different 
observers  vary  somewhat.  The  following,  proposed  by 
Dr.  Bright,  will,  I  think,  be  found  most  useful : 

The  abdomen  may  be  divided  into  three  general  zones 
— the  epigastric,  the  umbilical,  and  the  hypogastric. 

The  Epigastric  zone  is  bounded  above  by  the  dia- 
phragm, and  below  by  a  horizontal  plane  passing  through 
the  anterior  extremities  of  the  tenth  rib  on  either  side; 
carried  backward,  this  plane  will  pass  between  the  bodies 
of  the  first  and  second  lumbar  vertebrae.  In  a  well- 
formed  chest  the  cartilage  of  the  tenth  rib  on  either 
side  offers  a  projection  at  its  lower  convex  border,  which 
can  be  felt  without  difficulty.  This  zone  is  subdivided 
into  the  epigastric  and  the  right  and  left  hypochon- 
driac regions,  which  correspond  to  the  spaces  bounded 
by  the  false  ribs. 

'The  Umbilical  zone  is  bounded  above  by  the  lower 
boundary  of  the  epigastric,   and  below  by  a  horizontal 


THE    HYPOGASTRIC    ZONE. 


133 


plane  passing  through  the  anterior  and  superior  spinous 
processes  of  the  ilia ;  this  plane,  if  carried  backward, 
will  pass  between  the  second  and  third  sacral  spines. 

The  Hypogastric  zone  is  bounded  above  by  the  lower 
boundary  of  the  umbilical  zone,  below,  in  the  centre, 
by  the  upper  margin  of  the  pubes,  on  either  side  by 
Poupart's  ligament.    This  zone  occupies  the  whole  cavity 


Fig.  17.— Diagram  showing  the  different  Regions  of  the  Abdomen,  and  the  Organs 
contained  in  each,  which  are  visible  on  the  removal  of  the  Abdominal  Walls. 

of  the  true  pelvis.  The  umbilical  and  hypogastric  zones 
have  each  three  subdivisions,  made  by  two  vertical  planes 
passing  backward  through  the  spinous  processes  of  the 
pubes  and  the  points  on  the  tenth  ribs  already  alluded 
to.  The  subdivisions  of  the  umbilical  zone  thus  pro- 
duced are  termed  the  central  or  umbilical,  and  two 
lateral,  or  the  right  and  left  lumbar.     The    subdivisions 


134  PHYSICAL   DIAGNOSIS. 

of  the  hypogastric  thus  produced  consist  of  the  middle 
or  pubic,  and  the  lateral  or  right  and  left  iliac. 

The  organs  contained  in  these  regions  in  health  are  as 
follows  : 

The  Epigastric  region  contains  the  whole  of  the  left 
and  a  part  of  the  right  lobe  of  the  liver,  the  gall  bladder, 
the  pyloric  orifice  of  the  stomach,  the  commencement  of 
the  duodenum,  a  portion  of  the  colon,  the  jDancreas,  the 
abdominal  aorta,  and  the  cceliac  axis.  It  is  very  neces- 
sary to  understand  the  relative  positions  of  these  organs. 

The  Eight  Hypochondriac  region  contains  nearly  the 
whole  of  the  right  lobe  of  the  liver,  the  angle  of  the  as- 
cending and  a  portion  of  the  transverse  colon,  the  greater 
part  of  the  duodenum,  the  renal  capsule,  and  the  upper 
portion  of  the  right  kidney. 

The  Left  Hypochondriac  region  contains  the  rounded 
cardiac  portion  of  the  stomach,  at  all  times,  and  a  very 
large  portion  of  the  organ  when  distended,  the  left  angle 
of  the  colon,  the  spleen,  and  a  small  portion  of  the  left 
kidney  with  its  renal  capsule. 

The  Umbilical  region  is  chiefly  occupied  by  a  portion 
of  the  transverse  colon,  the  omentum,  and  the  small 
intestines.  It  contains,  likewise,  the  mesentery  and  its 
glands,  the  aorta,  and  the  inferior  vena  cava. 

The  Eight  Lumbar  region  contains  the  caecum,  the 
ascending  colon,  the  lower  and  middle  portions  of  the 
kidney,  and  a  portion  of  the  ureter. 

The  Left  Lumbar  region  is  occupied  by  the  descend- 
ing colon,  the  left  kidney,  and  the  ureter.  A  portion  of 
the  small  intestine  also  occupies  the  lumbar  region  on 
each  side. 

The  Pubic  or  Hypogastric  region,  in  children,  con- 
tains the  urinary  bladder,  with  portions  of  the  ureters 
(if  they  be  distended,  also  in  adults),  the  convolutions  of 


PHYSICAL   EXAMINATION   OP   THE   ABDOMEN.  135 

the  small  intestine,  and,  in  the  female,  the  uterus  and 
its  appendages. 

The  Right  Iliac  region  contains  the  "cul-de-sac"  of 
the  caput  coli,  the  vermiform  process,  and  the  iliac 
vessels. 

The  Left  Iliac  region  contains  the  sigmoid  flexure  of 
the  colon  and  the  iliac  vessels  of  that  side. 

Methods  Employed  in  the  Physical  Examinations  of  the 

Abdomen. 

They  are  the  same,  with  the  exception  of  succussion, 
as  those  practised  in  exploration  of  the  thorax,  but  they 
differ  in  their  relative  importance.  In  thoracic  exami- 
nations, auscultation  is  the  most  important  method, 
while  in  abdominal  examinations  auscultation  is  only 
employed  in  determining  the  existence  of  aneurisms  and 
of  pregnancy.  Percussion  and  palpation  are  the  means 
by  which  we  gain  the  most  useful  information  concern- 
ing the  contents  of  the  abdominal  cavity. 

Before  considering  the  signs  which  indicate  the 
changes  occurring  in  the  different  affections  of  the 
abdominal  organs,  I  will  briefly  notice  the  different 
methods  of  exploration. 

Inspection. — By  it  we  note  alterations  in  the  shape 
and  movements  of  the  abdomen.  It  is  most  satisfacto- 
rily performed  with  the  patient  lying  on  the  back  and 
the  thighs  slightly  flexed.  In  health,  the  abdomen  is  of 
an  oval  form,  marked  by  elevations  and  depressions  cor- 
responding to  the  abdominal  muscles,  the  umbilicus,  and 
in  some  degree  by  the  form  of  the  subjacent  viscera  ;  it 
is  larger,  relatively  to  the  size  of  the  chest,  in  children 
than  in  adults ;  more  rotund,  and  broader  inf  eriorly,  in 
females  than  in  males. 

Alterations  in  its  shape  due  to  disease  are,  first,  en- 


136  PHYSICAL   DIAGNOSIS. 

largement,  which  may  be  general  and  symmetrical,  as  in 
ascites ;  or  partial  and  irregular,  from  tumors,  hyper- 
trophy of  organs,  as  the  liver  and  spleen,  or  from  tym- 
panitic distention  of  portions  of  the  intestines  by  gas,  as 
of  the  colon  in  typhoid  fever ;  second,  retraction,  as  in 
extreme  emaciation,  and  in  several  forms  of  cerebral 
disease ;  especially  is  this  noticeable  in  the  tubercular 
meningitis  of  children. 

The  respiratory  movements  of  the  abdominal  walls 
bear  a  certain  relation  to  the  movements  of  the  thorax. 
They  are  often  increased  when  the  latter  are  arrested, 
and  vice  versa.  Thus,  abdominal  movements  are  in- 
creased in  pleurisy,  pneumonia,  pericarditis,  etc. ;  but 
decreased,  or  wholly  suspended,  when  disease  causes 
abdominal  pain,  or  in  peritonitis. 

Not  infrequently,  when  inspecting  the  abdomen,  a  dis- 
tinct pulsation  will  be  visible  in  the  epigastric  region, 
which  frequently  is  mistaken  for  aneurism.  The  super- 
ficial abdominal  veins  are  also  at  times  visibly  enlarged, 
indicating  an  obstruction  to  the  current  of  blood  either 
in  the  portal  system,  as  in  cirrhosis,  or  in  the  inferior 
vena  cava. 

Mensuration  is  mainly  useful  in  determining  the  ex- 
act increase  or  decrease  of  abdominal  dropsies,  visceral 
enlargements,  and  tumors.  It  is  performed  by  means 
of  a  graduated  tape. 

Palpation. — This  method  of  exploration  often  fur- 
nishes important  information.  It  may  be  performed 
with  the  tips  of  the  fingers,  with  the  whole  hand,  or 
with  both  hands,  and  the  pressure  may  be  slight  or  for- 
cible, continuous  or  intermitting.  In  order  to  obtain 
the  greatest  amount  of  information  by  palpation,  the 
patient  should  be  placed  in  a  horizontal  position,  with 
the  head  slightly  raised  and  the  thighs  flexed;   some- 


PHYSICAL   EXAMINATION   OF   THE   ABDOMEN.  13? 

times  it  is  necessary  to  place  him  in  a  standing  position 
or  leaning  forward. 

Indications  furnished  by  Palpation. — By  it  we  can 
determine  the  size  and  position  of  the  viscera,  the  exist- 
ence of  tumors  and  swellings,  whether  they  are  super- 
ficial or  deep,  large  or  small,  hard  or  soft,  smooth  or 
nodulated,  movable  or  fixed,  solid  or  liquid,  and  whether 
or  not  they  possess  a  motion  of  their  own.  We  can  also 
ascertain  if  tenderness  exist  in  any  portion  of  the  ab- 
dominal cavity,  and  if  pain  is  increased  or  relieved  by 
firm  pressure. 

Percussion. — In  the  performance  of  abdominal  per- 
cussion, the  patient  should  be  placed  in  the  same  posi- 
tion as  for  palpation,  and  the  percussion  should  be  for 
the  most  part  mediate.  In  exploring  the  abdomen  by 
means  of  percussion,  the  pleximeter  (the  finger  being 
the  best)  should  first  be  placed  immediately  below  the 
xiphoid  cartilage,  pressed  firmly  down  and  carried  along 
the  median  fine  toward  the  pubes,  striking  it  all  the 
way,  now  forcibly,  now  gently.  The  different  tones 
which  the  stomach,  colon,  and  small  intestine  furnish 
will  be  distinctly  heard.  The  percussion  should  then  be 
made  laterally,  alternately  to  one  side  and  then  to  the 
other,  until  the  whole  surface  is  percussed  (Bennet).  In 
this  manner  the  different  percussion  sounds  of  the  sto- 
mach, large  intestine,  small  intestine,  and  the  solid  vis- 
cera will  be  readily  distinguished.  Thus,  the  percussion 
sound  elicited  over  a  healthy  abdomen  may  be  dull,  flat, 
or  tympanitic.  Over  the  central  portion  of  •  the  fiver, 
spleen,  and  kidneys  the  percussion  sound  is  flat;  over 
that  portion  of  either  of  these  organs  where  they  overlap 
the  intestines  or  stomach  it  is  dull,  with  a  tympanitic 
quality.  Over  the  stomach  and  intestines  it  is  tympa- 
nitic, more  so  over  the  former  than  the  latter.     When 


138  PHYSICAL   DIAGNOSIS. 

liquid  occupies  the  abdominal  cavity,  over  the  liquid  the 
percussion  sound  will  be  flat.  A  distended  bladder  or 
uterus,  an  enlarged  liver,  spleen,  kidney,  or  mesenteric 
gland,  ovarian,  aneurismal,  and  other  tumors,  are  recog- 
nized and  their  limits  determined  by  the  unnatural  and 
increased  area  of  the  percussion  flatness ;  while,  on  the 
other  hand,  gaseous  distention  of  the  stomach  or  intes- 
tines is  recognized  by  the  increased  area  of  tympanitic 
percussion. 

Auscultation. — For  the  physical  exploration  of  the 
abdomen,  auscultation  is  only  of  service,  as  we  have  said 
before,  in  the  diagnosis  of  aneurisms,  in  detecting  the 
fcetal  heart  sounds  and  the  utero-placental  murmur  in 
the  pregnant  state. 

Our  examinations  of  the  abdominal  viscera  are  some- 
times interfered  with  and  rendered  uncertain  by  changes 
that  occur  in  the  abdominal  walls.  Generally  the  ab- 
dominal walls  are  sufficiently  thin,  soft,  and  movable  for 
us  to  determine  with  considerable  accuracy  the  situation 
and  condition  of  the  contained  organs  ;  if,  however, 
everything  is  masked  by  layer  upon  layer  of  fat,  as  in 
some  cases  of  obesity,  abdominal  examinations  will  be 
unsatisfactory.  An  oedematous  condition  of  the  abdomi- 
nal walls,  as  in  Bright's  disease,  may  also  prevent  us 
from  ascertaining  the  condition  of  the  viscera.  "When 
this  occurs,  the  surface  of  the  abdomen  presents  a 
smooth,  even,  shiny,  waxy  appearance,  and  pits  on  firm 
pressure.  Superficial  abscess  of  the  abdominal  walls 
also  occurs  occasionally,  and  interferes  greatly  with  the 
exploration  of  the  abdominal  cavity.  You  can  recog- 
nize this  by  the  circumscribed  bulging,  by  tenderness 
on  slight  pressure,  by  the  redness  of  the  surface,  and  by 
the  characteristic  fluctuation  of  a  superficial  abscess. 

The  abdominal  muscles  are  sometimes  abnormally  de- 


ASCITES.  139 

veloped,  or  unnaturally  rigid  as  in  tetanus,  rheumatic 
inflammation,  and  in  the  early  stage  of  peritonitis,  and 
this  somewhat  interferes  with  our  examinations. 


Diseased  Conditions  of  the  Peritoneum. 

Under  this  head  may  be  included  the  various  results 
of  inflammatory  action,  ascites,  etc.  They  all  give  rise 
to  more  or  less  abdominal  enlargement. 

Acute  Peritonitis. — By  inspection  we  recognize  in 
acute  peritonitis  either  a  diminution  or  an  entire  suspen- 
sion of  abdominal  respiration,  the  breathing  becoming 
entirely  thoracic.  The  abdomen  enlarges,  becomes  un- 
naturally tympanitic,  and  there  is  marked  tenderness  on 
firm  pressure.  The  comparative  results  of  firm  and 
slight  pressure  is  one  of  the  strong  diagnostic  marks  of 
peritoneal  inflammation. 

Chronic  Peritonitis  is  almost  always  connected  wTith 
tubercular  or  cancerous  deposits  in  the  substance  and 
over  the  free  surface  of  the  peritoneum  ;  and  in  addition 
to  the  tympanitic  distention  of  the  abdomen,  and  the 
tenderness  on  firm  pressure,  noticed  in  acute  peritonitis, 
liquid  accumulations  take  place  in  the  peritoneal  cavity. 

Ascites. — A  collection  of  liquid  from  any  cause  in  the 
peritoneal  cavity  is  termed  ascites. 

Inspection. — The  abdomen  is  always  uniformly  en- 
larged, and  the  movements  of  the  abdomen  in  respi- 
ration are  either  suspended  or  limited  to  the  epigastric 
region.  The  superficial  abdominal  veins,  if  the  ascites 
depend  upon  disease  of  the  liver,  will  often  be  found 
enlarged. 

Palpation. — If  the  palmar  surface  of  the  hand  be  ap- 
plied to  the  side  of  the  abdomen  at  the  level  of  the 
liquid,  and  light  percussion  be  performed  on  the  oppo- 


140  PHYSICAL,  DIAGNOSIS 

site  side,  a  sense  of  fluctuation  will  be  communicated  to 
the  hand. 

Percussion  gives  flatness  at  the  lower  and  most  de- 
pending portion  of  the  abdomen,  while  at  the  upper  por- 
tion, above  the  level  of  the  liquid,  there  is  a  drum-like, 
tympanitic  resonance.  When  the  patient  is  in  the  erect 
posture,  the  tympanitic  resonance  is  confined  to  the  epi- 
gastrium and  upper  portion  of  the  umbilical  region.  If 
in  a  recumbent  posture,  the  tympanitic  resonance  will 
extend  into  the  hypogastrium  ;  if  placed  on  either  side, 
the  lumbar  region  of  the  opposite  side  becomes  tym- 
panitic. 

Other  diseases  that  occur  in  the  peritoneum  consist  of 
enlargements,  and  may  be  classed  under  the  head  of  ab- 
dominal tumors. 


LESSOR  XT. 

PHYSICAL   SIGNS   OF    THE   ABNORMAL   CHANGES  IN  THE 

DIFFERENT   ABDOMINAL  ORGANS — STOMACH — 

INTESTINES — LIVER — SPLEEN. 

Stomach. 

When  this  viscus  is  empty,  or  not  distended  with 
gas  or  food,  there  is  on  inspection  no  visible  prominence 
to  indicate  its  position,  nor  does  palpation  furnish  us 
any  information  as  to  its  condition. 

Percussion  gives  a  metallic  or  tympanitic  resonance 
which  enables  us  to  distinguish  it  from  the  surrounding- 
viscera.  The  hue  of  dulness  which  marks  the  lower 
border  of  the  liver  and  the  inner  border  of  the  spleen 
determines  the  upper  and  lateral  boundaries  of  the 
stomach.  To  ascertain  the  lower  border,  percuss  gently 
downward  from  this  hue  of  dulness,  until  a  slight 
change  in  the  percussion  sound  indicates  that  you  have 
reached  the  transverse  colon  (see  Fig.  17,  page  133). 
Opposite  the  inner  border  of  the  seventh  rib,  on  the 
left  side,  the  cardiac  orifice  of  the  organ  is  situated.  At 
a  point  a  little  below  the  lower  border  of  the  liver,  within 
a  line  drawn  from  the  right  nipple  to  the  umbilicus,  the 
pyloric  orifice  of  the  organ  is  situated.  The  lower  mar- 
gin of  the  great  " cul-de-sac"  is  found,  generally,  near 
the  umbilicus. 

Diminution  in  the  size  of  the  stomach  cannot  be  rec- 
ognized by  physical  exploration.  An  increase  in  size  or 
distention  of  the  stomach  may  occur  from  an  accumu- 


142  PHYSICAL  DIAGNOSIS. 

lation  of  gas,  from  large  quantities  of  liquids  or  solids 
taken  into  the  stomach  ;  or  it  may  be  enlarged  within 
circumscribed  spaces  from  cancerous  deposit  in  its  walls. 

Gaseous  or  Tympanitic  distention  of  the  stomach  is 
recognized  by  an  increase  in  the  area  of  the  characteris- 
tic tympanitic  resonance  of  the  organ.  A  distended  con- 
dition of  the  stomach  from  food  or  drink  is  recognized 
by  an  absence  of  the  normal  resonance,  and  by  a  contin- 
uation of  the  dull  percussion  of  the  liver  and  spleen 
downward  to  the  umbilicus.  A  moderate  amount  of 
liquid  or  solid  in  the  stomach  can  be  determined  by  a 
limited  area  of  dulness  corresponding  to  the  "  cul-de-sac  " 
of  the  organ. 

Cancer  op  the  Stomach  most  frequently  has  its  seat 
at  the  pyloric  extremity  of  the  organ  ;  but  in  whatever 
portion  of  the  organ  it  may  be  developed,  it  can  be  rec- 
ognized by  circumscribed  dulness  on  percussion,  where 
in  health,  when  the  stomach  is  empty,  we  should  have 
tympanitic  resonance.  The  percussion  dulness  elicited 
over  the  cancerous  mass,  however,  has  a  hollow  charac- 
ter which  is  readily  distinguished  from  the  flat  percussion 
sound  of  a  solid  organ. 

By  palpation  a  nodulated  mass  is  readily  detected,  cor- 
responding to  the  area  of  percussion  dulness,  which  is 
movable,  easily  grasped,  and  readily  separated  from  the 
surrounding  viscera.  These  signs,  taken  in  connection 
with  the  attendant  symptoms,  are  almost  always  suffi- 
cient for  a  positive  diagnosis. 

Intestines. 

In  a  normal  condition  the  large  intestine  furnishes 
a  more  amphoric  percussion  sound  than  the  stomach. 
When,  however,  it  is  filled  with  liquid  or  solid  accumula- 
tions, the  situation  of  these  accumulations  can  be  marked 
out  on  the  surface  by  the  dulness  on  percussion. 


INTESTINES.  14.3 

The  peculiar  feel  of  such  enlargements  will  generally 
enable  you  to  decide  as  to  their  true  character :  they 
feel  like  no  other  tumors.  On  examining  them  through 
the  abdominal  walls,  they  are  felt  to  be  hard  and  resist- 
ant ;  but  if  one  finger  be  pressed  steadily  upon  them  for 
one  or  two  minutes,  they  will  at  last  indent  like  a  hard 
snowball.  There  is  not  the  slightest  elasticity  about 
them,  and  the  indentation  remains  after  the  pressure  is 
removed  (Simpson).  As  these  accumulations  most  fre- 
quently collect  in  the  descending  colon,  the  percussion 
sound  over  this  portion  is  usually  less  resonant  than  over 
the  ascending  or  transverse  colon.  According  to  Dr. 
Bennet,  in  a  practical  point  of  view  it  is  often  useful  to 
determine  whether  a  purgative  by  the  mouth  or  an 
enema  is  likely  to  open  the  bowels  most  rapidly.  If 
there  is  dulness  in  the  left  iliac  fossa  in  the  track  of  the 
descending  colon,  that  portion  of  the  intestine  must  be 
full  of  faeces,  and  an  enema  is  indicated.  If,  on  the 
other  hand,  the  sound  in  the  left  iliac  fossa  is  tympa- 
nitic, and  in  the  right  dull,  an  enema  is  of  little  service, 
as  it  will  not  extend  to  the  caecum,  and  purgatives  by 
the  mouth  are  indicated.  Sometimes  the  whole  colon, 
or  the  transverse  portion,  or,  what  is  more  common,  the 
sigmoid  flexure  of  the  large  intestine,  becomes  distended 
with  faecal  accumulations,  giving  rise  to  circumscribed 
abdominal  enlargement  and  to  flatness  on  percussion 
over  that  portion  of  the  abdomen  which  corresponds  to 
the  situation  of  the  intestines.  Care  must  be  taken  not 
to  confound  this  condition  with  an  enlarged  liver,  spleen^ 
tumors,  etc.  The  percussion  sound  over  the  small  intes- 
tine, unless  it  is  distended  with  gas,  is  higher  pitched 
and  less  amphoric  than  that  of  the  surrounding  large 
intestine.  There  are  no  physical  signs  to  indicate  the 
abnormal  changes  which  occur  in  this  portion  of  the  all- 


144  PHYSICAL  DIAGNOSIS. 

mentary  canal,  except   an  increase  in  the   tympanitic 
resonance  which  exists  when  it  is  distended  with  gas. 

Liver. 

Our  diagnosis  in  any  case  of  hepatic  disease  rests 
mainly  on  the  size,  form,  and  position  of  the  liver  as  de- 
termined by  percussion  and  palpation.  The  first  step, 
then,  in  studying  the  physical  signs  indicative  of  disease 
of  this  organ,  is  to  become  familiar  with  its  normal 
boundaries.  In  its  healthy  state,  the  right  lobe  of  the 
liver  occupies  the  right  hypochondrium,  lying  completely 
in  the  hollow  formed  by  the  diaphragm,  rarely  descend- 
ing below  the  free  border  of  the  ribs,  or  extending  up- 
ward above  the  fifth  intercostal  space ;  the  left  lobe 
reaches  across  to  the  left  of  the  median  line  an  inch  or 
more  (see  Fig.  17,  page  133). 

The  upper  boundary  of  the  organ  is  determined  by  per- 
cussing with  moderate  force  from  the  right  nipple  down- 
ward until  the  flatness  of  the  percussion  sound  indicates 
that  a  solid  organ  has  been  reached.  Indicate  this  point 
with  an  aniline  peDcil.  Then  percuss  downward  from 
the  axilla,  and  also  from  a  point  a  little  to  the  right  of 
the  median  line  in  front,  in  the  same  manner,  until  a 
change  occurs  in  the  percussion  sound.  Indicate  these 
points  on  the  chest  wall  with  the  pencil.  A  line  drawn 
through  the  three  points  marks  the  upper  boundary  of 
the  liver.  Generally  it  will  be  found  to  correspond  to 
the  base  of  the  ensiform  cartilage  on  the  median  line  in 
front,  to  the  fifth  intercostal  space  on  the  line  of  the 
right  nipple,  to  the  seventh  rib  in  the  axillary  region,  and 
to  the  ninth  rib  in  the  dorsal  region.  The  lower  boun- 
dary of  the  organ  is  determined  by  percussing  downward 
from  the  line  of  flatness  already  determined,  and  noting 
the  points  where  the  tympanitic  sounds  of  the  stomach 


NORMAL   BOUNDARIES    OF    LIVER.  145 

and  large  intestine  occur.  Usually  it  will  be  found  to 
correspond,  anteriorly,  to  the  free  border  of  the  ribs,  and 
to  a  point  three  inches  below  the  ensiform  cartilage  on 
the  median  line  ;  laterally,  in  the  axillary  region,  to  the 
tenth  intercostal  space  ;  and  posteriorly,  in  the  dorsal 
region,  to  the  twelfth  rib.  The  flatness  of  the  left  lobe 
usually  reaches  two  inches  to  the  left  of  the  median  line. 
The  whole  margin  of  the  liver,  except  where  it  comes  in 
contact  with  the  apex  of  the  heart  through  the  medium 
of  the  diaphragm,  may  thus  be  determined  and  marked 
out  on  the  surface.  The  vertical  measurements  will  be 
found  very  nearly  as  follows  :  On  the  right  of  the  me- 
dian line  in  front,  three  inches  ;  on  a  line  with  the 
right  nipple,  four  inches  ;  in  the  axillary  region,  four 
and  one-half  inches ;  and  in  the  dorsal  region,  four 
inches.  The  smooth  edge  of  the  lower  margin  of  the 
liver  in  health,  especially  in  thin  subjects,  can  be  dis- 
tinctly felt  behind  the  free  border  of  the  ribs. 

The  healthy  liver  in  its  normal  position  influences  very 
little  the  percussion  sound  over  the  soft  portion  of  the 
abdomen.  As  already  stated,  the  sound  is  tympanitic 
from  the  free  borders  of  the  ribs  to  the  pubes  when  the 
abdominal  organs  are  normal  and  empty.  If,  therefore, 
the  percussion  sound  is  flat,  and  the  flatness  is  uninter- 
rupted upward  to  the  margin  of  the  ribs  on  the  right 
side,  we  have  good  reason  for  believing  that  the  liver 
is  the  organ  diseased. 

The  gall  bladder  is  found  where  the  lower  border  of 
the  liver  passes  under  the  ribs  on  the  right  side,  just 
within  the  nipple  line. 

The  normal  boundaries  of  the  liver,  already  defined, 
may  be  greatly  altered  without  any  abnormal  change 
occurring  in  the  organ  itself.    These  normal  changes,  un- 
less remembered,  may  lead  to  errors  in  diagnosis.    Thus, 
10 


146 


PHYSICAL   DIAGNOSIS. 


congenital  malformations  may  give  rise  to  an  increase 
in  the  area  of  hepatic  dulness.  An  accurate  history  of 
the  patient,  however,  will  keep  us  from  error  in  such 
cases.  In  the  examination  of  children,  also,  it  should  be 
remembered  that  the  liver  is  proportionately  larger  than 
in  adults. 

The  practice  of  tight  lacing  may  cause  displacement 


\  (K-~> 


Fig.  18.— The  volume  of  the  Liver  in  Various  Diseases.  5-10,  Ribs.  I,  Position  of  the 
diaphragm  in  the  highest  degree  of  tumefaction  of  the  liver  (carcinoma) .  II,  II,  Nor- 
mal position  of  the  diaphragm,  n,  ni,  Relative  dulness.  HI,  Position  of  the  dia- 
phragm at  the  anterior  wall  of  the  chest,  at  the  same  time  the  line  of  dulness  of  the 
normal  liver.  IV,  Edge  of  liver  in  cirrhosis.  V,  In  the  normal  liver.  VI,  Fatty  liver. 
VII,  Amyloid  liver.  VIII,  Cancer,  leukaemia,  adenoma.  All  of  proportional  size.— 
After  Rendfleisch. 

and  malformation  of  the  liver,  and  thus  give  rise  to  ap- 
parent hepatic  enlargement.  The  marks  which  this 
practice  leaves  on  the  chest  walls  will  be  sufficient  to  at- 
tract our  attention  and  so  prevent  mistake. 

Diseases  of  the  thoracic  organs  and  abnormal  condi- 
tions of  the  other  abdominal  viscera  sometimes  cause 


WAXY   LIVER.  147 

displacement  of  the  liver,  simulating  very  closely  hepat- 
ic enlargement :  these  we  will  consider  under  the  head 
of  differential  diagnosis  of  diseases  of  the  liver. 

VARIATIONS  IN  THE  SIZi:  OF  THE  LIVER  IN  HEPATIC  DISEASES. 

Variations  in  the  size  of  the  liver  occur  in  almost  every 
disease  to  which  it  is  subject. 

It  is  increased  in  size  in  fatty  liver,  in  waxy  liver,  in 
abscess  of  liver,  in  congestion,  in  acute  hepatitis,  in  ob- 
struction of  the  bile  ducts,  in  cancer,  in  hydatid  cyst 
and  other  tumors.  It  is  diminished  in  size  in  atrophic 
cirrhosis  and  in  acide  yelloiv  atrophy.  Enlargements  of 
the  liver  were  divided  by  Dr.  Bright  into  smooth  and 
irregular.  Dr.  Murchison  has  divided  them  into  painless 
and  painful  enlargements.  Both  of  these  divisions,  it 
seems  to  me,  have  their  objections,  and  in  giving  the 
physical  signs  of  the  various  diseases  accompanied  by 
enlargement  of  the  organ,  it  is  hardly  practicable  to 
adopt  either  of  them  exclusively. 

Fatty  Liver. — In  fatty  infiltration  of  the  liver  the 
organ  is  uniformly  enlarged,  there  are  no  circumscribed 
bulgings,  its  normal  shape  is  unaltered,  there  is  no  ex- 
pansion of  the  lower  ribs,  it  never  gives  rise  to  ascites, 
and  it  is  not  attended  by  any  visible  enlargement  of  the 
superficial  veins.  On  palpation  a  soft,  cushion-like  en- 
largement is  readily  detected  below  the  margin  of  the 
ribs  on  the  right  side,  and  in  the  epigastrium,  extending 
not  infrequently  as  low  as  the  umbilicus  ;  its  outer  sur- 
face is  smooth,  and  its  lower  margin  is  rounded  and  not 
well  defined  ;  it  is  never  tender  on  pressure.  On  percus- 
sion there  is  flatness  over  the  surface  of  the  abdomen 
corresponding  to  the  enlargement. 

Waxy  Liver. — In  waxy  or  amyloid  degeneration,  the 
organ  undergoes  greater  enlargement  than  in  fatty  in- 


148  PHYSICAL  DIAGNOSIS. 

filtration  ;  it  often  becomes  so  large  as  to  fill  the  whole 
abdominal  cavity  ;  its  growth  is  slow,  usually  extending 
over  a  period  of  two  or  three  years.  The  enlargement 
is  uniform,  and  the  area  of  hepatic  dulness  is  conse- 
quently increased  on  percussion  in  every  direction — 
more,  however,  in  front  than  behind.  There  is  often  a 
visible  tumor  below  the  margin  of  the  ribs,  but  there  is 
no  bulging  of  the  ribs  themselves.  On  palpation  that 
portion  of  the  organ  below  the  ribs  is  dense,  firm,  and 
resistant ;  the  outer  surface  is  smooth ;  the  lower  mar- 
gin is  sharp  and  well  defined.  Pain  and  tenderness  are 
rarely  present,  so  that  the  portion  of  the  organ  below 
the  ribs,  as  in  fatty  infiltration,  can  be  manipulated 
without  giving  the  patient  any  inconvenience.  When 
excessive,  it  is  almost  always  accompanied  by  ascites. 

Abscess  of  the  Liver. — An  abscess  may  occur  in  any 
part  of  the  liver.  It  depends  entirely  upon  its  situation 
whether  an  external  tumor  is  produced  or  not.  If  the 
abscess  occupies  the  posterior  portion  of  the  right  lobe, 
the  fiver  is  pushed  down  so  that  its  margin  is  perceptible 
below  the  free  border  of  the  ribs,  and  the  flatness  on  the 
right  side,  posteriorly,  extends  higher  than  normal.  If 
the  abscess  is  superficial  and  is  pointing  externally,  a 
distinct  tumor  is  felt,  and  there  is  always  more  or  less 
bulging  of  the  ribs-  if  the  right  lobe  is  affected.  Some- 
times the  organ  is  enormously  enlarged,  its  free  border 
extending  below  the  umbilicus  ;  the  surface  of  the  en- 
largement is  smooth,  and  it  is  usually  tender  on  pres- 
sure. The  sensation  to  the  examiner  on  making  light 
pressure  will  be  soft  and  fluctuating,  or  that  of  elastic 
tenseness.  In  some  rare  instances  abscesses  produce 
an  uneven  or  lobulated  condition  of  the  surface  ;  under 
such  circumstances  they  may  be  mistaken  for  cancer, 
unless  the  rational  symptoms  and  history  of  the  case  be 


CANCER    OF    THE    LIVER.  149 

included  in  the  elements  of  diagnosis.  The  enlargement 
goes  on  rapidly.  With  a  correct  history  of  the  case, 
the  diagnosis  is  easily  made. 

Congestion  of  the  Liver. — The  most  simple  form 
of  hepatic  enlargement  is  that  which  results  from  con- 
gestion. When  the  liver  is  thus  loaded  with  blood,  a 
slight  fulness  is  perceptible  on  the  right  side.  On  pal- 
pation the  space  immediately  below  the  ribs  is  occu- 
pied by  a  smooth,  hard,  resisting  enlargement  corre- 
sponding to  the  natural  shape  of  the  liver.  Usually  it  is 
not  tender  on  pressure.     There  is  no  well-defined  tumor. 

On  percussion  a  flat  sound  is  elicited  an  inch  or  two 
below  the  margin  of  the  ribs,  on  the  right  side. 

Obstruction  of  the  Bile  Ducts  will  produce  an  en- 
largement of  the  liver,  similar  to  the  one  just  noticed,  by 
preventing  the  outflow  of  bile.  Sometimes,  in  addition 
to  the  general  enlargement  detected  by  the  slight  uni- 
form increase  in  the  area  of  hepatic  dulness,  a  globu- 
lar projection  is  found  at  a  point  corresponding  to  the 
transverse  fissure.  It  has  the  elastic  feel  of  deep- 
seated  fluid.     This  tumor  is  the  distended  gall  bladder. 

Acute  Hepatitis. — The  physical  signs  of  acute  hepa- 
titis' do  not  differ  materially  from  those  of  simple  con- 
gestion, except  in  the  excessive  tenderness  that  exists 
on  pressure  over  that  portion  of  the  organ  which  de- 
scends below  the  ribs. 

Cancer  of  the  Liver. — In  most  cases  of  cancer  the 
diagnosis  is  easily  made. 

On  Percussion  the  area  of  the  hepatic  dulness  is  al- 
ways increased,  sometimes  extremely  so.  The  organ  is 
found  to  occupy  the  greater  portion  of  the  epigastrium, 
extending  beyond  the  median  line  into  the  left  hypo- 
chondrium,  pushing  the  diaphragm  upward,  and  often 
descending  below  the  ribs  to  the  crest  of  the  ilium. 


150  PHYSICAL   DIAGNOSIS. 

On  Palpation  irregular  nodules  of  various  sizes  are 
distinctly  felt  through  the  abdominal  walls,  projecting 
from  that  portion  of  the  enlarged  organ  which  is  below 
the  free  border  of  the  ribs.  These  prominences  are 
usually  harder  than  the  surrounding  hepatic  tissue,  and 
there  is  more  or  less  tenderness  on  pressure  over  them. 
Cancer  of  the  liver  may,  or  may  not,  be  accompanied  by 
ascites. 

Occasionally  the  surface  of  the  liver  in  cancer  is  per- 
fectly smooth,  and  in  such  cases  you  will  be  unable  to 
detect  the  disease  by  the  physical  signs. 

Hydatid  Tumors  of  the  Liver. — Hydatid  cysts,  when 
small  or  deep-seated,  cannot  be  detected  by  physical 
examination ;  but,  when  large  or  superficially  seated, 
they  are  recognized  by  abnormal  increase  in  the  area 
of  hepatic  dulness,  and  by  the  globular  form  of  the 
enlargement  on  the  surface  of  the  organ.  Sometimes 
these  cysts  are  so  large  as  to  cause  the  organ  to  fill  a 
large  portion  of  the  abdominal,  and  encroach  on  the 
right  pleural,  cavity.  The  natural  form  of  the  organ  is 
greatly  altered,  the  enlargement  taking  place  more  in 
one  direction  than  in  another.  Sometimes  percussion 
over  a  large  hydatid  cyst  will  give  rise  to  a  characteristic 
vibration  known  as  hydatid  fremitus.  This  vibration  is 
produced  by  the  impulse  of  the  smaller  cysts  that  are 
contained  in  a  large  one.  A  hydatid  liver  encroaching 
on  the  thoracic  cavity  gives  rise  to  flatness  on  percus- 
sion, and  absence  of  respiratory  sound,  from  the  base  of 
the  chest  upward  as  far  as  the  tumor  extends  :  the 
upper  boundary  of  the  flatness  is  arched.  It  is  distin- 
guished from  pleuritic  effusion  in  that  a  change  in  the 
position  of  the-  body  does  not  change  the  line  of  percus- 
sion dulness.  On  palpation,  sometimes  the  enlarged 
portion  below  the  ribs  has  an  elastic  or  even  fluctuating 


CIRRHOSIS   OF   THE   LIVER.  151 

feel,  and  if  a  large  cyst  be  near  the  surface  it  may  give 
rise  to  a  sense  of  fluctuation.  The  surface  over  these 
enlargements  is  smooth,  the  organ  is  not  tender  on  pres- 
sure, and  its  growth  is  slow. 

DECREASE  IN  THE   SIZE   OF  THE  LIVER. 

The  liver  is  diminished  in  size  in  atrophic  cirrhosis 
and  in  acute  yellow  atrophy. 

Cirrhosis  of  the  Liver. — In  fully  developed  cases  of 
atrophic  cirrhosis  of  the  liver,  the  organ  is  always  di- 
minished in  size,  and  there  is  more  or  less  abdominal 
dropsy.  The  only  evidence  of  this  disease  furnished  by 
inspection  is  a  visible  enlargement  of  the  superficial 
veins. 

Percussion. — The  normal  area  of  the  hepatic  dulness 
is  diminished.  Its  limits  are  determined  as  follows  :  if 
the  abdominal  cavity  is  distended  with  dropsical  accu- 
mulations, the  patient  should  be  placed  partly  on  the  left 
side,  so  that  the  liquid  will  gravitate  from  the  hepatic 
region  ;  the  percussion  dulness  then,  instead  of  extend- 
ing to  the  free  border  of  the  ribs,  will  often  give  place  to 
tympanitic  resonance  an  inch  or  more  above  their  free 
margin,  and  instead,  also,  of  extending  across  the  me- 
dian line  into  the  left  hypochondrium,  will  rarely  reach 
that  line ;  while  the  vertical  measurement  of  hepatic 
dulness  on  a  line  with  the  right  nipple  often  does  not 
exceed  two  and  a  half  inches. 

Palpation. — Little  nodules  will  often  be  felt  on  the 
under  surface  of  the  liver,  by  making  firm  pressure  with 
the  ends  of  the  fingers  under  the  free  border  of  the  ribs. 
Sometimes,  when  the  distention  of  the  abdomen  from 
dropsical  accumulation  has  been  very  great,  we  can  get 
no  information  by  palpation  until  after  the  performance 
of  paracentesis. 


152  PHYSICAL  DIAGNOSIS. 

Atrophy  of  the  Liver. — The  only  physical  sign  of 
atrophy  of  the  liver  is  the  rapid  diminution  in  size,  de- 
termined by  percussion.  Its  surface  remains  smooth. 
The  diminution  in  size  is  never  accompanied  by  ascites. 

DIFFERENTIAL    DIAGNOSIS  OF    DISEASES  OF  THE    LIVER. 

Conditions  which  may  lead  to  the  erroneous  diagnosis 
that  the  liver  is  diseased  are  faecal  accumulations  in  the 
ascending  and  transverse  colon,  enlargement  of  the  right 
kidney,  diseases  of  the  stomach,  displacement  of  the 
liver  by  disease  in  the  right  side  of  the  chest,  enlarge- 
ment of  the  spleen,  tumors  of  the  omentum,  and  ovarian 
tumors. 

Faecal  Accumulations. — To  distinguish  these  accu- 
mulations from  enlargement  of  the  liver,  by  physical 
examination,  is  always  difficult  and  sometimes  impossi- 
ble. They  give  rise  to  a  distinct  tumor,  below  the  border 
of  the  ribs,  which  by  percussion  and  palpation  seems  to 
be  continuous  and  connected  with  the  liver.  The  feel  of 
these  f aacal  enlargements,  already  referred  to,  is  charac- 
teristic. The  differential  diagnosis  sometimes,  however, 
can  only  be  made  after  the  trial  of  remedies  which,  acting 
freely  on  the  bowels,  remove  the  accumulations  and  cause 
the  disappearance  of  the  supposed  hepatic  enlargement. 

Disease  of  the  Eight  Kidney. — The  right  kidney 
sometimes  enlarges  in  such  a  manner  as  to  present  itself 
as  a  tumor  extending  from  the  under  surface  of  the 
right  lobe  of  the  liver.  It  may  be  distinguished  from  an 
hepatic  tumor  by  carefully  examining  its  relation  to  the 
ribs.  As  the  patient  lies  on  his  back,  the  enlargement, 
instead  of  passing  up  under  the  ribs,  dips  down,  so  as  to 
allow  the  finger  to  pass  vertically  between  the  ribs  and 
the  tumor.  Furthermore,  the  position  of  an  enlarged 
kidney  is  not  altered  by  a  deep  inspiration. 


SPLEEN.  153 

Diseases  of  the  Stomach. — The  only  disease  of  the 
stomach  which  we  are  likely  to  confound  with  enlarge- 
ment of  the  liver  is  cancer.  Usually,  however,  it  can  be 
readily  distinguished  from  hepatic  enlargement  by  the 
tympanitic  quality  of  the  percussion  sound  over  the' 
cancerous  mass,  and  by  the  mobility  of  the  mass. 

Displacements  of  the  Liver  downward  from  ex- 
tensive pleuritic  effusion,  and  from  pneumothorax,  are 
recognized  by  the  presence  of  the  physical  signs  which 
indicate  these  thoracic  diseases. 

Enlargement  of  the  Spleen  and  Ovarian  Tumors 
are  distinguished  from  enlargements  of  the  liver  by  the 
shape  of  the  tumor,  and  by  the  continuous  and  increas- 
ing flatness  of  the  percussion  sound  as  we  pass  toward 
the  normal  position  of  these  organs. 

Spleen. 

The  obscurity  which  surrounds  the  normal  physiologi- 
cal action  of  the  spleen  is  so  great  that  its  affections  usu- 
ally give  rise  to  but  negative  general  symptoms  ;  and  be- 
cause of  its  relation  to  the  surrounding  organs,  it  often 
presents  greater  difficulties  in  the  diagnosis  of  its  mor- 
bid conditions  than  is  the  case  with  any  other  abdominal 
organ.  In  health  this  organ  occupies  the  upper  portion 
of  the  left  hypochondriac  region,  its  lower  border  touches 
the  left  kidney,  while  its  convex  surface  occupies  the 
concavity  of  the  diaphragm.  It  is  bounded  posteriorly 
above  by  the  lower  border  of  the  ninth  rib  ;  anteriorly 
by  the  stomach  and  left  colon  ;  and  inf eriorly  by  the 
free  margins  of  the  ribs.  It  is  about  four  inches  long 
and  three  wide.  In  its  healthy  condition,  inspection  and 
palpation  furnish  only  negative  results. 

Percussion. — To  determine  the  boundaries  of  the 
spleen  by  percussion,  it  is  necessary  that  the  patient 


154 


PHYSICAL  DIAGNOSIS. 


should  lie  on  the  right  side.  Its  anterior  border  is 
readily  determined  because  of  its  relation  to  the  stomach 
and  intestine.  Inferiorly,  where  the  organ  comes  in 
contact  with  the  kidney,  it  is  difficult  and  often  impos- 
sible to  determine  its  boundary.  Its  superior  border 
corresponds  to  the  line  which  marks  the  change  from 
dulness  to  pulmonary  resonance. 
In  disease  the  spleen  may  be  increased  or  diminished 


Fig.  19.— Diagram  representing  the  different  Areas  occupied  by  the  Spleen  in  its 
various  Enlargements  into  the  Abdominal  Cavity.— Bright. 


in  size  ;  but  we  are  rarely,  if  ever,  able  to  recognize  dimi- 
nution in  its  size  during  life.  In  most  cases  of  splenic 
disease  there  is  neither  pain  nor  tenderness.  The  only 
reliable  physical  signs  are  those  of  enlargement.  The 
tumor  produced  can  scarcely  be  overlooked.  Its  charac- 
teristics are  a  smooth,  oblong,  solid  mass,  felt  immedi- 
ately beneath  the  integuments,  extending  from  under 
the  ribs  on  the  left  side,  a  little  behind  the  origin  of  the 


SPLEEN.  155 

cartilages  ;  often  advancing  to  the  median  line  in  one 
direction,  and  descending  to  the  crest  of  the  ilium  in  the 
other,  filling  the  left  lumbar  region  at  its  upper  part. 
This  tumor  is  usually  movable,  rounded  at  its  upper  por- 
tion, and  presenting  an  edge  more  or  less  sharp  in  front, 
where  it  is  often  notched  and  fissured. 

The  principal  tumors  which  may  be  mistaken  for  an 
enlarged  spleen  are,  chronic  abscess  of  the  integuments, 
cancer  of  the  stomach,  enlargement  of  the  left  lobe  of 
the  liver,  cancer  of  the  omentum,  faecal  accumulation 
in  the  colon,  disease  of  the  left  kidney,  and  ovarian 
disease. 

Chronic  Abscess  in  the  Abdominal  Wall  sometimes 
occurs  precisely  in  the  situation  of  an  enlarged  spleen, 
but  it  is  easily  distinguished  from  it  by  the  superficial 
character  of  the  swelling,  and  by  its  being  too  soft  to 
belong  to  an  internal  viscus. 

Cancerous  Deposit  in  the  cardiac  extremity  of  the 
stomach  sometimes  gives  rise  to  a  tumor,  which,  descend- 
ing from  the  margin  of  the  ribs,  might  be  mistaken  for 
an  enlarged  spleen.  One  of  the  best  distinctive  marks 
will  be  found  in  the  sound  elicited  by  forcible  percus- 
sion :  it  has  more  or  less  of  a  tympanitic  resonance, 
while  the  tumor  is  harder  to  the  feel  than  an  enlarged 
spleen. 

Enlarged  Left  Lobe  of  the  Liver  is  easily  distin- 
guished from  enlarged  spleen  ;  for  the  margin  of  the 
tumor  can  be  traced  running  toward  the  right,  and  not 
toward  the  left  as  is  the  case  with  enlarged  spleen. 

Cancerous  and  Tubercular  Enlargements  of  the 
omentum  are  distinguished  from  an  enlarged  spleen  by 
the  fact  that  they  extend  across  the  abdomen,  and  can- 
not be  traced  backward  ;  they  do  not  ascend  behind  the 
ribs,  and  are  rough,  hard,  and  uneven. 


156  PHYSICAL  DIAGNOSIS. 

Faecal  Accumulation  in  the  intestine  is  a  source  of 
very  great  difficulty  in  this  diagnosis,  for  when  it  takes 
place  in  the  descending  colon,  at  the  sigmoid  flexure,  the 
enlargement  assumes  very  nearly  the  situation  of  an  en- 
larged spleen,  and  is  scarcely  to  be  distinguished  from  it 
except  by  its  peculiar  feel,  by  its  history,  and  by  the 
results  of  cathartics ;  nor  must  we  conclude  that  the 
intestines  have  been  emptied,  without  the  most  persever- 
ing employment  of  purgatives  and  enemata. 

The  Left  Kidney  sometimes  enlarges  toward  the  left 
hypochondrium,  and  presents  a  tumor  very  nearly  in  the 
situation  of  an  enlarged  spleen  ;  but  by  tracing  it  back 
toward  the  loins,  we  shall  find  that  its  chief  bulk  is  situ- 
ated posteriorly.  It  is  much  more  fixed  ;  is  not  forced 
downward  by  a  full  inspiration ;  and  if  the  patient  is 
placed  on  his  hands  and  knees,  it  does  not  fall  forward. 
In  enlargements  of  the  kidney,  the  intestine  is  always 
pushed  forward  ;  this  is  never  the  case  with  the  spleen. 
By  observing  the  'rules  for  the  diagnosis  of  ovarian 
tumors,  we  shall  easily  distinguish  them  from  enlarged 
spleen  (Bright). 


LESSOR  XVI. 

PHYSICAL  SIGNS   OF    THE  ABNORMAL   CHANGES   IN   THE 
DIFFERENT  ABDOMINAL  ORGANS — CONTINUED. 

Kidneys,  Bladder,  Uterus,  Ovaries,  Aneurisms, 
Omentum,  Mesentery. 

Kidneys. 

The  kidneys  in  health  are  situated  in  the  lumbar  re- 
gions, as  shown  in  Fig.  2,  in  the  space  corresponding  to 
the  two  lower  dorsal  and  the  two  upper  lumbar  vertebrae. 
The  right  is  a  little  lower  than  the  left.  Superficially, 
they  extend  from  the  eleventh  rib  to  the  crest  of  the 
ilium.  The  right  is  bounded  above,  by  the  posterior 
and  inferior  portion  of  the  right  lobe  of  the  liver  ;  below, 
by  the  caecum  ;  anteriorly,  by  the  descending  portion  of 
the  duodenum  and  the  ascending  colon  ;  and  posteriorly, 
by  the  diaphragm  and  quadratus  lumborum.  The  left 
is  bounded  above,  by  the  spleen  ;  anteriorly,  by  the  stom- 
ach and  descending  colon  ;  inf  eriorly,  by  the  descending 
colon  ;  and  posteriorly,  by  the  diaphragm  and  quadra- 
tus lumborum. 

In  disease  the  kidneys  may  be  increased  or  diminished 
in  size.  Diminution  in  the  size  of  the  kidneys  can  rarely 
be  determined  by  physical  examination,  so  that  enlarge- 
ments are  the  only  conditions  to  which  physical  ex- 
ploration is  applicable.  The  kidneys  may  be  enlarged 
from  pyelitis,  which  sometimes  converts  them  into  a 
sac  of  pus  ;  cancerous  and  tubercular  deposits,  hydatid 
cysts,  and  simple  distention,  the  result  of  an  obstructed 


158  PHYSICAL  DIAGNOSIS. 

ureter.     A  tumor  is  sometimes  developed  at  the  upper 
border  of  a  kidney,  from  disease  of  the  suprarenal  capsule. 

Inspection  rarely  furnishes  any  evidence  of  enlarge- 
ment of  a  kidney. 

Palpation  of  the  kidney  is  to  be  practised  as  follows  : 
The  patient  is  placed  in  the  dorsal  position,  with  the 
thighs  flexed.  One  hand  is  placed  over  the  seat  of  the 
kidney  in  the  lumbar  region,  and  firm  pressure  is  made. 
The  fingers  of  the  other  hand  are  placed  below  the  free 
border  of  the  ribs,  on  a  line  running  through  the  middle 
of  Poupart's  ligament.  "With  each  expiration  the  fingers 
are  pressed  deeper  and  deeper  until  the  renal  tumor  is 
reached.  The  part  of  the  abdomen  in  which  the  enlarged 
kidney  is  felt  will  vary  according  to  the  nature  of  the 
disease  and  the  portion  of  the  kidney  involved. 

Percussion. — Unless  the  kidney  is  much  enlarged,  the 
results  of  percussion  are  uncertain.  In  performing  per- 
cussion, the  patient  should  be  placed  on  the  abdomen 
and  chest,  which  posture  will  allow  liquid  accumula- 
tions in  the  abdominal  cavity  to  gravitate  forward,  and 
the  intestines  to  float  upward.  The  external  margin 
of  the  kidney  is  determined  when  the  tympanitic  note  of 
the  intestine  is  reached.  Any  enlargement  will  be  ac- 
companied by  a  corresponding  increase  in  the  area  of 
renal  dulness.  We  can  rarely  establish  by  a  physical 
examination  the  exact  nature  of  the  disease  to  which  the 
increase  in  size  is  due. 

The  sources  of  error  in  the  diagnosis  of  enlargements 
of  the  kidneys  vary,  according  as  the  right  or  left  kidney 
is  the  seat  of  disease. 

Enlargement  of  the  right  kidney  may  be  mistaken  for 
a  tumor  of  the  right  lobe  of  the  liver,  for  cancer  of  the 
pyloric  extremity  of  the  stomach,  for  faecal  distention  of 
the  colon,  and  for  enlargement  of  the  right  ovary.     The 


BLADDER.  159 

rules  for  distinguishing  it  from  each  of  these  have  been 
already  given  in  the  previous  section,  as  likewise  for 
distinguishing  enlargements  of  the  left  kidney  from  en- 
largement of  the  spleen,  the  left  ovary,  and  from  faecal 
distention  of  the  descending  colon. 

Movable  Kidney. — This  is  not  properly  a  disease,  but 
a  structural  peculiarity  in  certain  individuals.  The 
right  kidney  is  more  often  affected  than  the  left.  The 
attachments  of  the  kidney  are  so  loose  that  the  organ 
can  be  displaced,  either  vertically  or  laterally,  to  a  con- 
siderable degree,  and  may  so  approach  the  anterior  ab- 
dominal walls  as  to  be  readily  felt  through  them.  It 
may  be  found  in  the  umbilical  region,  or  even  across  the 
median  line.  It  can  be  detected  best  by  drawing  up  the 
feet  to  retract  the  abdomen,  then  grasping  the  tumor 
with  the  palm  of  the  hand.  It  has  a  smooth,  rounded 
feel,  and  differs  from  mesenteric  tumors  or  faecal  ac- 
cumulations in  disappearing,  on  gentle  pressure,  into  the 
abdominal  cavity,  so  that  it  cannot  be  felt.  When  the 
kidney  is  displaced,  the  corresponding  lumbar  region 
gives  a  tympanitic  sound  on  percussion. 

Bladder. 

When  the  bladder  is  empty,  its  position  cannot  be 
determined  by  physical  exploration.  It  can  only  be  de- 
tected when  it  is  distended  and  rises  above  the  pubes.  It 
then  appears  as  a  tumor  in  the  hypogastric  region, 
which  on  palpation  is  smooth  and  oval.  Its  rounded 
margin  is  easily  made  out  by  observing  the  tympanitic 
sound  of  the  intestines  on  the  one  hand,  and  the  dull 
sound  of  the  bladder  on  the  other.  In  infants,  the  blad- 
der is  not  as  deep  in  the  pelvis  as  in  adults,  consequently 
a  smaller  quantity  of  urine  in  the  bladder  can  be  recog- 
nized.    A  distended   bladder  can  only  be  mistaken  in 


160  PHYSICAL  DIAGNOSIS. 

the  female  for  a  gravid  uterus  or  a  uterine  tumor : 
the  use  of  a  catheter  removes  all  doubts. 

Uterus. 

The  unimpregnated  uterus  in  its  normal  state  is  situ- 
ated in  the  lower  part  of  the  hypogastrium,  and  is 
inaccessible  to  the  touch,  externally,  or  to  percussion ; 
but  when  normally  enlarged  by  impregnation,  or  abnor- 
mally by  disease,  palpation,  percussion,  and  ausculta- 
tion furnish  us  with  important  information. 

In  pregnancy,  at  the  end  of  the  second  month,  a  dull 
sound  on  percussion,  just  above  the  pubes,  indicates  the 
enlarging  uterus  ;  later,  as  the  uterus  increases  in  vol- 
ume and  rises  into  the  abdomen,  we  are  able,  by  the 
oval  tumor  felt  in  the  hypogastrium,  and  by  the  circum- 
scribed area  of  dulness  corresponding  to  the  situation  of 
the  tumor,  to  establish  strong  presumptive  evidence  of 
pregnancy.  The  presumption  becomes  strengthened  if 
the  area  of  the  dulness  increases  with  the  regularity 
proper  to  gestation.  But  palpation  and  percussion  are 
not  sufficient  to  determine  whether  the  enlargement 
of  the  uterus  is  due  to  pregnancy,  or  to  some  morbid 
deposit  in  its  walls  or  cavity,  as  fibrous  tumors,  etc. 

After  the  end  of  the  fifth  month,  the  evidence  fur- 
nished by  both  these  methods  is  inferior  to  auscultation. 
•  Eules  for  Performing  Uterine  Auscultation. — The 
female  should  be  placed  on  her  back,  with  her  thighs 
slightly  flexed  so  as  to  relax  the  abdominal  muscles'; 
sometimes  it  is  well  to  incline  the  body  from  one  side  to 
the  other,  or  forward  so  as  to  withdraw  the  pressure 
of  the  uterus  from  the  pelvic  arteries.  The  abdomen 
should  be  uncovered,  as  the  sounds  to  be  examined  are 
of  slight  intensity  and  their  area  is  very  circumscribed. 
Their  study  demands  close  attention  and  perfect  silence. 


UTERINE   BRUIT.  161 

The  stethoscope  is  alwa/s  to  be  preferred,  and  the  ute- 
rine tumor  should  be  auscultated  successively  at  different 
points. 

After  the  fourth  month  of  gestation,  if  the  uterus  con- 
tains a  living  foetus,  we  may  hear  three  distinct  sounds 
— the  Uterine  Bruit,  which  is  evidently  connected  with 
the  circulation  of  the  mother  ;  the  Foetal  Heart  Sound, 
and  the  Funic  Souffle,  which  are  connected  with  the 
circulation  of  the  foetus. 

Uterine  Bruit. — This  sound  is  single,  intermitting, 
and  in  character  is  a  combination  of  the  blowing  and 
hissing  sounds.  It  increases  in  intensity  up  to  the 
period  of  labor.  It  is  believed  to  depend  upon  the  rapid 
passage  of  blood  from  the  arteries  into  the  distended 
venous  sinuses  of  the  uterus.  It  is  synchronous  with 
the  maternal  pulse,  is  subject  to  the  same  variations, 
and  is  always  heard  before  the  pulsation  of  the  foetal 
heart. 

The  Area  over  which  it  is  audible  varies.  In  some  in- 
stances it  is  limited  to  a  single  point,  in  others  it  is  aud- 
ible over  a  surface  of  three  or  four  inches,  and  in  a  few 
it  is  heard  over  the  whole  uterine  tumor,  although  there 
will  always  be  one  spot  of  greatest  intensity,  correspond- 
ing to  the  placental  attachment.  It  is  also  .intensified 
by  uterine  contractions,  though  at  the  height  of  the  pain 
it  may  cease  altogether.  It  may  be  modified  or  arrested 
by  pressure  on  the  stethoscope. 

During  the  first  half  of  pregnancy  it  is  usually  heard 
with  greatest  intensity  in  the  median  line,  a  little  above 
the  pubes  ;  after  the  fifth  month,  at  the  lateral  and  in- 
ferior borders  of  the  uterus  ;  and  next,  in  order  of  time, 
it  will  be  heard  at  the  fundus. 

This  sound  may  be  confounded  with  the  respiratory 
murmur  of  the  mother,  and  with  intestinal  murmurs  : 
11 


162  PHYSICAL   DIAGNOSIS. 

these  murmurs,  however,  are  not  synchronous  with  the 
pulse  of  the  mother,  and  if  this  fact  is  remembered  there 
will  be  little  difficulty  in  distinguishing  them.  As  a 
proof  of  pregnancy,  uterine  bruit  is  not  positive,  as  it 
is  sometimes  heard  in  connection  with  uterine  and  ova- 
rian tumors.  It  does  not  prove  that  the  foetus  is  alive, 
for  it  is  heard  for  a  long  time  after  its  death.  Its  nega- 
tive evidence  is  of  less  value,  for  if  the  placenta  is  attached 
posteriorly  we  may  not  be  able  to  hear  it,  although 
pregnancy  exist. 

Funic  Souffle. — This  sound  is  usually  heard  at  a  point 
quite  remote  from  the  uterine  bruit.  It  is  short,  fee- 
ble, and  blowing  in  character,  and  corresponds  in  preg- 
nancy with  the  foetal  pulsation.  It  is  supposed  to  depend 
upon  obstruction  to  the  transmission  of  blood  through 
the  umbilical  arteries,  as  from  twirling  or  knotting  of 
the  funis,  or  from  external  pressure.  It  is  not  a  con- 
stant, nor  even  a  frequent  sound,  the  conditions  of  its 
production  being  rarely  met  with. 

Foetal  Heart  Sound. — This  sound  consists  of  a  suc- 
cession of  short,  rapid,  double  pulsations,  varying  in 
frequency  from  120  to  140  per  minute.  The  first  sound 
is  short,  feeble,  and  obscure,  while  the  second,  the  one 
we  usually  hear,  is  loud  and  distinct,  and  may  be  heard 
generally  over  the  body  of  the  child.  This  sound  has 
been  aptly  compared  to  the  ticking  of  a  watch  wrapped 
in  a  napkin,  and  usually  is  first  heard  at  the  middle 
of  the  fourth  month.  The  frequency  of  the  pulsations 
does  not  vary  with  the  age  of  the  foetus. 

The  extent  over  which  the  foetal  heart  sound  is  aud- 
ible varies  ;  usually  it  is  transmitted  over  a  space  three 
or  four  inches  square.  The  location  of  the  sound  is 
determined  by  the  position  of  the  foetus.  It  has  been 
stated  that  whenever  the  maximum  intensity  of  this 


FCETAL    HEART    SOUND.  163 

sound  is  below  a  horizontal  line  dividing  the  uterus  into 
equal  parts,  it  is  a  vertex  presentation ;  when  above,  it 
is  a  breech  ;  also,  when  the  f  cetal  pulsations  are  heard 
low  down  in  front  on  the  left  side,  that  the  foetus  is  in 
the  first  position ;  if  heard  below  and  in  front,  on  the 
right  side,  it  is  in  the  second  position. 

Twin  pregnancy  may  sometimes  be  determined  by  the 
presence  of  heart  sounds  heard  at  distant  points  over 
the  uterine  tumor,  and  by  the  absence  of  synchronism 
in  the  two  pulsations.  The  sources  of  deception  in  ex- 
ploring for  the  foetal  heart  sound  are  the  liability  of 
confounding  the  pulsation  of  the  iliac  arteries  or  abdom- 
inal aorta  of  the  mother  with  it.  In  most  cases  their 
situation,  comparative  frequency,  and  absence  of  double 
pulsation  will  determine  their  character.  But  a  diffi- 
culty will  sometimes  occur  in  discriminating  between 
them  when  the  natural  pulse  is  very  much  increased  in 
frequency  and  the  fcetal  diminished.  Under  such  cir- 
cumstances we  must  be  guided  by  the  character  of  the 
sound,  and  whether  it  is,  or  is  not,  synchronous  with  the 
radial  pulse. 

Again,  in  the  early  stage  of  pregnancy,  the  intensity 
and  impulse  of  the  maternal  pulsation  may  render  the 
feeble  foetal  sound  inaudible.  This  difficulty  may  be 
overcome  by  removing  the  pressure  of  the  uterine  tumor 
upon  the  subjacent  arteries,  by  changing  the  posture  of 
the  mother. 

During  labor  our  examinations  should  be  made  in  the 
interval  between  uterine  contractions. 

In  protracted  labors,  auscultation  is  of  value  in  indi- 
cating to  us  the  time  for  manual  or  instrumental  inter- 
ference to  save  the  life  of  the  child.  The  indications  of 
danger  to  the  child  are  feebleness  or  excessive  frequency 
of  the  foetal  pulsation  ;  irregularity  in  its  rhythm  ;  ab- 


164  PHYSICAL  DIAGNOSIS. 

sence  of  the  second  sound  ;  its  complete  cessation  during 
uterine  contraction,  and  the  slowness  of  its  return  in  the 
interval.  Irregularity  and  feebleness  are  the  most  threat- 
ening to  the  life  of  the  child.  When  the  sound  of  the 
foetal  heart  is  heard  it  is  a  positive  proof  of  pregnancy  ; 
but  its  absence  is  not  always  proof  that  pregnancy  does 
not  exist,  for  the  foetus  may  be  dead,  and  in  some  rare 
cases  the  sounds  may  exist  and  be  quite  inaudible  for  a 
time,  and  then  appear.  This  phenomenon  is  not  easily 
accounted  for. 

Tumors  of  the  Uterus,  whether  developed  on  its  sur- 
face, in  its  walls,  or  within  its  cavity,  give  rise  to  en- 
largement of  the  organ,  which  causes  it  to  occupy  a 
position  corresponding  to  that  occupied  by  a  gravid 
uterus.  The  position  and  extent  of  these  enlargements 
are  determined  in  the  same  manner  as  we  determine  the 
size  and  position  of  the  uterus  in  pregnancy.  Deposits 
in  its  walls  or  on  its  surface  give  rise  to  nodules,  which 
feel  through  the  abdominal  walls  like  hard  balls,  vary- 
ing in  size  and  shape,  seldom  occurring  singly.  The 
whole  mass  can  usually  be  moved  from  one  side  to  the 
other.  The  connection  of  these  tumors  with  the  uterus, 
as  determined  by  the  uterine  sound,  leaves  little  doubt  as 
to  their  true  character,  and  by  this  means  we  readily 
distinguish  them  from  all  other  abdominal  tumors. 

Ovaries. 

The  ovaries  in  a  normal  state  lie  in  the  pelvic  cavity, 
and  their  position  cannot  be  determined  by  physical  ex- 
ploration ;  but  when  they  become  the  seat  of  tumors, 
and  have  attained  such  dimensions  that  there  is  no  long- 
er room  for  them  in  the  pelvic  cavity,  they  ascend  above 
its  brim  and  occupy  more  or  less  space  among  the  ab- 
dominal organs.     As  they  pass  out  of  the  pelvis,  they 


OVARIAN  TUMORS.  165 

are  first  noticed  in  the  right  or  left  iliac  region,  accord- 
ing as  the  right  or  left  ovary  is  affected,  and  they  are 
then  recognized  as  ovarian  tnmors.  Before  these  ovarian 
enlargements  have  attained  sufficient  size  to  attract  the 
attention  of  the  patient,  they  will  have  reached  a  cen- 
tral position  in  the  abdominal  cavity.  They  are  of  more 
frequent  occurrence  than  any  other  forms  of  abdominal 


Fig.  20.— Diagram  showing  the  Gradual  Enlargement  of  a  Tumor  of  the  Right  Ovary- 
till  it  fills  a  large  portion  of  the  Abdominal  Cavity.— Bright. 

tumor,  and  their  existence  is  determined  almost  exclu- 
sively by  the  physical  signs  which  they  furnish. 

Inspection. — In  the  early  part  of  their  development, 
an  uneven  projection  or  prominence  of  one  part  of  the 
abdomen  will  disclose  the  seat  of  the  tumor,  occupying 
usually  the  iliac  or  lumbar  region  of  one  side,  and  ex- 
tending upward  to  or  beyond  the  umbilicus ;  while  in 
more  advanced  cases  no  inequality  will  be  visible,  but 


166  PHYSICAL   DIAGNOSIS. 

the  rounded  form  of  the  abdomen,  while  the  patient  lies 
on  her  back,  offers  a  strong  contrast  to  the  flattened 
oval  appearance  of  ascites,  or  the  central  rounded  form 
of  a  uterus  distended  by  pregnancy. 

Palpation. — Ovarian  tumors,  when  small,  have  a  firm, 
elastic  feel ;  but  when  large,  they  are  soft  and  fluctuat- 
ing. In  some  cases,  by  passing  the  hand  gently  over  the 
abdomen,  the  extent  of  the  tumor  will  be  readily  appre- 
ciated. At  other  times,  the  limits  of  the  tumor  cannot 
be  ascertained  by  gentle  palpation,  for  it  occupies  the 
whole  of  the  abdomen  except  the  concavity  of  the  dia- 
phragm. In  such  cases,  by  making  firm,  but  not  forci- 
ble, pressure  on  various  parts  of  the  abdomen,  we  often 
detect  at  once  a  general  sense  of  fluctuation,  and  ascer- 
tain inequalities  which  neither  the  eye  nor  the  hand 
when  passed  gently  over  the  surface  will  enable  us  to 
detect ;  sometimes,  if  the  abdomen  is  not  tense,  we  can 
feel  masses  which  convey  the  impression  of  more  or  less 
flattened  or  spherical  bodies  attached  to  the  inside  of  a 
fluctuating  tumor.  In  some  cases  the  sense  of  fluctu- 
ation is  very  indistinct  ;  in  others  it  is  even  more  evi- 
dent than  in  cases  of  extensive  ascites. 

Percussion. — The  sound  elicited  on  percussion  is  flat 
over  that  portion  of  the  abdomen  where  the  tumor 
comes  in  contact  with  the  inner  surface  of  the  ab- 
dominal wall ;  while  at  the  sides  and  above,  where  the 
intestines  have  been  pushed  aside  and  upward  by  the 
tumor,  the  percussion  sound  will  be  tympanitic  ;  by  this 
change  in  the  percussion  sound  we  are  enabled  to  mark 
out  the  boundaries  of  the  tumor. 

Differential  Diagnosis. — Ovarian  tumors  may  be  con- 
founded in  their  diagnosis  with  uterine  enlargements,  as 
'pregnancy,  fibroid  tumors  of  the  uterus,  etc.,  ascites, 
hydatids  of  the  omentum,  faical  accumulations  in  the 


OVARIAN  TUMORS.  167 

intestines,  and  enlargements  of  the  liver,  spleen,  and  kid- 
neys. 

They  are  distinguished  from  pregnancy  by  a  stethosco- 
pic  examination  of  the  tumor,  which  reveals  in  the  one 
case  the  sounds  of  the  foetal  heart,  and  in  the  other  their 
absence.  They  are  distinguished  from  uterine  tumors 
by  their  consistence,  by  their  outline,  by  the  difference 
in  their  connection  and  relative  position  to  the  uterus, 
and  by  the  fact  that  in  uterine  tumors  the  cavity  of  the 
uterus,  as  determined  by  the  uterine  sound,  is  always 
elongated.  The  diagnosis  between  ovarian  and  abdom- 
inal dropsy  is  made  :  First.  By  observing  the  difference 
in  the  shape  of  the  abdomen  when  the  patient  lies  on 
her  back.  Ovarian  tumors  project  forward  in  the  centre, 
while  in  ascites  the  abdominal  enlargement  is  uniform. 
Second.  In  ovarian  tumors,  the  percussion  sound  is  dull 
as  high  as  the  tumor  extends,  while  at  the  same  time 
there  will  be  tympanitic  resonance  in  the  most  depend- 
ing portion  of  the  abdominal  cavity  ;  in  ascites,  the  most 
depending  portion  of  the  abdomen  is  always  flat,  the 
percussion  resonance  being  confined  to  the  epigastric  and 
umbilical  regions.  Third.  In  ovarian  dropsy,  the  rela- 
tive line  of  flatness  and  resonance  is  not  altered  by 
change  in  the  posture  of  the  patient,  which  is  not  the 
case  in  ascites. 

Hydatids  of  the  omentum  form  a  class  of  tumors 
which  you  will  be  unable  to  distinguish  from  ovarian 
tumors  by  the  physical  signs.  The  fact,  however,  that 
these  omental  enlargements  are  first  noticed  above 
the  umbilicus  and  gradually  enlarge  downward,  while 
ovarian  are  first  noticed  low  down  in  the  abdomen  and 
gradually  enlarge  upward,  will  in  most  cases  be  suffi- 
cient for  a  diagnosis. 

Faecal  accumulations   in  the  large  intestine  may  be 


168  PHYSICAL   DIAGNOSIS. 

mistaken  for  ovarian  tumors.  The  peculiar  feel  of  such 
enlargements,  already  described,  will  enable  you  to  dis- 
tinguish them  from  ovarian  tumors. 

Abdominal  Aneurism. 

Aneurism  of  the  abdominal  aorta  usually  occurs  at  or 
near  that  portion  of  the  vessel  from  which  the  coeliac 
axis  is  given  off,  and  the  rupture  is  usually  in  the  poste- 
rior wall  of  the  artery.  Aneurism  of  the  coeliac  axis,  of 
the  renal,  hepatic,  superior  mesenteric,  or  splenic  arte- 
ries, is  of  very  rare  occurrence,  and  there  are  no  means 
by  which,  if  they  do  occur,  they  can  be  distinguished 
from  aneurism  of  the  abdominal  aorta. 

Inspection. — On  inspecting  the  abdomen  in  a  case  of 
abdominal  aneurism,  a  tumor  in  the  epigastrium,  with 
an  expansive  impulse,  usually  is  discovered ;  in  some 
cases,  however,  the  closest  inspection  reveals  nothing 
abnormal.  When  a  tumor  is  present,  the  surface  of  the 
abdomen  over  it  will  be  rounded  and  smooth.  When 
the  aneurism  is  of  large  size,  abdominal  respiration  may 
be  diminished  and  thoracic  increased.  Enlargement  of 
the  superficial  veins  of  the  abdomen,  and  oedema  of  the 
lower  extremities,  are  very  rare  phenomena. 

Palpation. — By  palpation  we  can  determine  approxi- 
mately the  size  of  the  tumor,  its  position,  and  its  im- 
pulse. 

Aneurisms  of  the  abdominal  aorta  are  usually  felt  in 
the  median  line,  or  to  the  left  of  it,  on  the  right  side,  or 
on  both  sides.  They  are  immovable.  The  impulse,  if 
one  exist,  is  systolic  and  expansive,  although  when  it  is 
situated  high  up  there  also  may  be  a  slight  diastolic 
movement.  A  thrill  is  rarely  perceptible.  By  compar- 
ing the  pulsation  in  the  arteries  of  the  lower  extremities 
with  that  of  the  upper,  a  feebleness  of  pulsation  may  be 


ABDOMINAL   ANEURISM.  109 

detected.  The  surface  of  the  tumor,  when  not  ruptured, 
is  rounded  and  smooth.  Effusions  of  blood  into  the  sur- 
rounding tissues  may  produce  lobulations. 

Percussion. — Dulness  or  flatness  will  exist  over  the 
tumor,  unless  a  distended  intestine  he  above  it. 

Auscultation. — A  systolic  murmur,  resembling  that 
produced  in  aneurisms  of  the  thoracic  aorta  (page  123), 
is  usually  heard  directly  over  the  tumor  in  front,  or  op- 
posite to  it  along  the  lumbar  spine  ;  rarely,  if  ever,  is 
a  diastolic  murmur  heard,  though  a  prolonged  second 
sound  often  exists.  In  some  cases,  the  murmur  is  aud- 
ible when  the  patient  is  in  the  recumbent  posture,  but 
disappears  when  he  assumes  the  erect  posture. J  In  other 
cases,  all  the  physical  signs  of  aneurism  are  absent,  and 
still  we  are  led  to  suspect  its  existence  from  the  rational 
symptoms,  the  most  prominent  of  which  is  a  continuous, 
deep-seated,  and  at  times  paroxysmal  pain  in  the  lum- 
bar region,  which  shoots  down  the  thighs  and  around 
the  abdomen. 

Abdominal  aneurism  may  be  mistaken :  First.  For 
enlargement  of  various  organs  which  by  its  size  it  has 
displaced,  as  the  liver,  kidney  (especially  the  left),  and 
the  spleen.  The  presence,  however,  of  the.  physical 
signs  of  aneurism  in  such  cases  will  enable  us  to  refer 
the  apparent  enlargement  to  its  right  source.  Second. 
For  neuralgia,  rheumatism,  renal  colic,  etc.  The 
steady,  persistent,  long-continued,  paroxysmal  pain 
in  the  lumbar  region,  especially  in  male  subjects,  is 
strong  presumptive  evidence  of  aneurism  ;  and  if  we 
have  connected  with  this  an  immovable,  although  per- 
haps not  pulsatile,  tumor  along  the  course  of  the  artery, 
the   diagnosis   of  aneurism    becomes    almost    positive. 

1  See  Intra-thoracic  Auscultation,  p.  39. 


170  PHYSICAL    DIAGNOSIS. 

Tliird.  For  disease  of  the  spine.  Here  the  pain,  and 
possibly  a  curvature  produced  by  an  aneurism,  may  mis- 
lead, but  the  physical  signs  of  aneurism  in  most  cases 
will  correct  the  mistake.  Fourth.  For  psoas  or  lumbar 
abscess.  In  this  the  shape  of  the  tumor  is  elongated, 
and  there  is  neither  impulse  nor  murmur  perceptible. 
Fifth.  For  aortic  pulsation.  In  aortic  pulsation  there 
is,  however,  absence  of  a  murmur,  or  a  thrill,  or  percus- 
sion dulness,  and  the  impulse  is  quick  and  jerking,  and 
not  expansive  as  in  aneurism.  Sixth.  For  abdominal 
tumors.  The  tumors  which  are  apt  to  be  mistaken  for 
aneurism  are  enlarged  left  lobe  of  liver,  cancer  of  the  py- 
lorus, enlarged  mesenteric  glands,  faecal  accumulations, 
and  hydro-  or  pyo-nephritic  kidney.  In  tumors  the  feel 
is  usually  harder,  the  impulse  lifting,  rarely  expansive, 
and  they  may  be  accompanied  by  ascites,  oedema,  or  en- 
larged abdominal  veins,  the  infrequency  of  which  in 
aneurism  has  already  been2  alluded  to.  If  a  murmur  oc- 
cur with  a  non-aneurismal  tumor,  it  may  be  made  to 
disappear  in  most  instances  by  causing  the  patient  to 
assume  a  posture  on  his  hands  and  knees  ;  the  impulse 
may  be  diminished  or  cease  at  the  same  time.  Tumors 
are  also  usually  movable,  aneurisms  immovable.  In 
many  cases  of  abdominal  aneurism  the  diagnosis  is  un- 
certain. 

Omental  Tumors. 

The  omentum  may  be  the  seat  of  a  hydatid  cyst,  of 
cancer,  or  of  tubercular  deposits.  These  deposits  or 
growths  give  rise  to  tumors  which  are  readily  detected 
through  the  abdominal  walls,  both  by  percussion  and 
palpation.  They  are  first  recognized  high  up  in  the  ab- 
dominal cavity,  above  the  umbilicus,  and  gradually  ex- 
tend downward.  If  there  are  no  adhesions,  you  can 
push  the  tumors  upward  and  from  right  to  left.     They 


MESENTERIC   ENLARGEMENTS.  171 

are  superficial,  and  their  uneven  surface  is  readily  de- 
tected by  passing  the  hand  lightly  over  the  surface  of 
the  abdomen.  They  are  always  more  or  less  tender 
on  firm  pressure.  The  percussion  sound  elicited  over 
these  tumors  is  never  flat,  but  has  a  tympanitic  qual- 
ity, caused  by  the  subjacent  intestines. 

Mesenteric  Enlargements. 

Mesenteric  enlargements  occupy  a  position  correspond- 
ing to  that  of  the  small  intestine.  They  are  beyond 
the  reach  of  physical  diagnosis,  except  as  they  occur  in 
children  in  the  last  stage  of  tabes  mesenterica  ;  then 
their  diagnosis  is  of  little  practical  use,  their  cure  being 
hopeless. 


EXAMINATION  OF  URINE. 


LESSOE"    XVII. 

INTRODUCTION — PLAN      OF        EXAMINATION — PHYSICAL 
CHARACTERS — CHEMICAL    CHARACTERS — (a)    NOR- 
MAL    ELEMENTS,     (6)     ABNORMAL     ELEMENTS. 

Gentlemen  : — You  will  find  that  the  examination  of 
the  urine  is  of  great  service  in  the  diagnosis  of  disease. 
In  order  that  it  shall  be  complete,  the  urine  should  be 
examined  both  chemically  and  microscopically. 

I  shall  first  direct  your  attention  to  the  chemical  ex- 
amination. (For  the  microscopical  examination,  see 
the  lesson  on  Clinical  Microscopy.)  This  involves  both 
qualitative  and  quantitative  analyses — the  former  to 
ascertain  the  presence  or  absence  of  particular  sub- 
stances ;  the  latter  to  determine  the  quantity  or  propor- 
tion in  which  they  exist  when  present. 

The  specimen  to  be  examined  should  be  taken  from 
the  urine  passed  on  rising  in  the  morning,  and  should 
be  collected  in  a  perfectly  clean  bottle  holding  from  four 
to  six  ounces. 

The  examination  should  be  conducted  after  the  follow- 
ing plan: 

Physical  Characters. 

1.  Quantity  passed  in  twenty-four  hours. 

2.  Condition  (transparent  or  turbid). 

3.  Color. 

4.  Odor. 

5.  Reaction. 

6.  Specific  gravity. 

7.  Character  of  deposit. 


176  PHYSICAL  DIAGNOSIS. 

Chemical  Characters. 


NORMAL  ELEMENTS. 

1. 

Urea. 

2. 

Uric  acid  and  the  urates. 

3. 

Phosphates. 

4. 

Chlorides. 

5. 

Sulphates. 

ABNORMAL  ELEMENTS. 

1. 

Albumin. 

2. 

Sugar. 

3. 

Bile. 

4. 

Blood. 

5. 

Pus. 

The  examination  should  be  made  within  twelve  hours 

after  the  urine  is 

voided  ;  in  warm  weather, 

even  earlier. 

Physical  Characters. 

Quantity  Passed  in  Twenty-four  Hours. — The 
amount  of  urine  voided  by  a  healthy  person  in  twenty- 
four  hours  greatly  varies.  The  mean  daily  discharge 
ranges  between  forty  and  fifty  fluid  ounces — it  may  rise 
as  high  as  eighty  ounces,  and  fall  as  low  as  twenty-five 
ounces,  and  still  be  within  the  limits  of  health,  the 
variation  depending  in  a  great  degree  upon  the  quantity 
of  fluid  drunk. 

In  order  accurately  to  determine  the  quantity  passed 
in  twenty-four  hours,  it  should  be  carefully  measured 
in  a  graduated  urine  glass. 

Before  determining  the  clinical  significance  of  any  de- 
viation from  the  usual  quantity  of  urine  passed  by  an 
individual,  Dr.  Eoberts  states  that  the  following  points 
should  be  borne  in  mind: 


CONDITION.  177 

When  the  urine  is  unusually  scanty,  it  should  be 
ascertained,  before  pronouncing  it  a  morbid  phenomenon, 
whether  the  patient  has  abstained  from  liquids  above  his 
habit,  or  whether  water  has  been  eliminated  in  excess 
by  some  other  channel,  as  the  skin  or  bowels.  The  urine 
is  always  scanty  in  fevers,  cirrhosis  of  the  liver,  and 
in  some  forms  of  Bright's  disease  through  their  entire 
course.  In  the  early  stage  of  acute  Bright's  disease 
it  is  very  scanty,  sometimes  approaching  or  reaching 
total  suppression.  It  is  also  scanty  in  any  condition  of 
the  heart  which  directly  or  indirectly  causes  passive 
congestion  of  the  renal  veins,  whereby  the  circulation 
through  the  kidneys  is  impeded.  It  becomes  scanty,  or 
is  suppressed,  in  the  collapse  stage  of  cholera. 

Any  diminution  of  the  urinary  secretion  which  ap- 
proaches suppression  is  of  most  serious  import. 

The  flow  of  urine  is  abundant  when  the  surface  of  the 
body  is  cool,  or  when  large  quantities  of  fluid  have  been 
taken.  In  disease  it  is  discharged  in  excessive  quantity 
in  two  special  maladies — diabetes  and  chronic  interstitial 
nephritis.  Temporary  excess  of  urine  occurs  after  hys- 
terical paroxysms,  certain  other  convulsive  attacks  in 
both  males  and  females,  and  after  mental  worry  or 
anxiety.  An  increased  tension  in  the  arterial  system, 
as  in  some  cases  of  hypertrophy  of  the  left  ventricle, 
is  associated  with  increased  secretion  of  urine. 

Condition. — Normal  urine  is  clear  when  first  voided, 
but  on  standing  a  slight  cloud  of  mucus  forms.  It 
comes  from  the  urinary  passages,  generally  the  bladder. 
Urine  is  rendered  cloudy  by  deposits  of  phosphates  or 
urates,  and  by  contamination  with  blood  or  pus.  Alka- 
line fermentation  produces  a  turbidity  of  the  urine  by 
bringing  about  the  decomposition  of  urea  and  the  pre- 
cipitation of  the  earthy  phosphates.     The  presence  of  fat 

12 


178  PHYSICAL  DIAGNOSIS. 

in  the  urine  as  an  emulsion  (chyluria)  gives  it  a  milky- 
appearance. 

Color. — In  health  the  color  of  the  urine  varies  from 
a  pale-straw  to  a  brownish-yellow  tint.  This  is  due 
to  the  presence  of  urobilin,  a  normal  pigment  of  the 
urinary  secretion.  But  the  color  may  be  altered  and  yet 
indicate  no  morbid  condition.  Certain  drugs  impart  an 
abnormal  color  to  the  urine.  Rhubarb  and  senna  give  it 
a  brown  or  reddish  color  ;  logwood,  a  reddish  or  violet 
color ;  while  creosote,  carbolic  acid,  and  tar  color  it 
black.  Again,  in  cases  of  melanotic  tumor  the  urine  is 
dark.  As  a  rule,  the  larger  the  quantity  of  urine  passed 
the  lighter  the  color,  and  vice  versa.  The  darker  color 
of  the  diminished  amount  is  due  to  a  relative  excess  of 
urobilin,  as  after  great  exertion  which  is  attended  by 
profuse  perspiration.  High-colored  urine,  when  a  nor- 
mal amount  is  passed,  is  an  indication  of  disease. 

Bile  communicates  a  dark  olive-green  tint  to  the  urine. 
An  admixture  of  blood  gives  the  urine  a  smoky  or  dis- 
tinctly reddish  appearance. 

The  red  color  of  rheumatic  urine  is  due  to  a  special 
pigment,  uroerythrin. 

Indican  is  a  pigment  normally  found  in  the  urine,  but 
to  what  extent  it  influences  the  color  is  not  known. 
Sometimes,  when  in  excess,  it  breaks  down  and  forms 
indigo-blue,  which  imparts  its  color  to  the  urine.  This 
may  occur  in  Asiatic  cholera  and  in  typhus  fever. 

Odor. — Healthy  human  urine,  immediately  after  void- 
ing, has  a  sweetish,  aromatic  odor.  But  the  odor  may 
be  changed  by  the  ingestion  of  certain  kinds  of  food  and 
the  administration  of  certain  medicines.  Asparagus 
gives  the  urine  a  disagreeable  stench  ;  garlic  imparts  its 
odor.  Turpentine  produces  the  odor  of  violets.  After 
alkaline  fermentation  the  pungent  odor  of  ammonia  is 


SPECIFIC    GRAVITY.  179 

perceptible.     A  fruity,  apple  odor  is  present  in  diabetes 
mellitus,  due  to  the  presence  of  acetone. 

Ee action. — When  first  passed,  healthy  urine  is  slightly 
acid  in  reaction.  This  is  due  to  the  presence  of  acid 
sodium  phosphate.  The  degree  of  acidity  varies  in  the 
twenty-four  hours.  After  each  meal  it  declines  for 
about  two  hours  until-  the  urine  is  neutral  or  even 
alkaline,  and  then  returns  to  the  normal.  The  reaction 
is  affected  by  the  kind  of  food  eaten  :  thus  an  animal 
diet  makes  the  urine  acid  ;  a  vegetable  diet,  alkaline. 
Fasting  is  marked  by  a  decided  increase  in  acidity. 

After  standing  for  some  time,  all  urine  becomes  alka- 
line from  the  decomposition  of  urea  and  the  formation 
of  ammonium  carbonate.  The  rapidity  with  which  this 
takes  place  varies  with  the  state  of  the  temperature.  In 
warm  weather  the  fermentation  begins  a  few  hours 
after  voiding. 

In  febrile  and  inflammatory  affections,  especially  of 
the  liver,  heart,  and  lungs,  the  urine  is  strongly  acid  ; 
while  in  affections  of  the  brain  and  spinal  cord,  and  cer- 
tain diseases  of  the  genito-urinary  organs,  it  is  often 
strongly  alkaline.  Urine  that  is  ammoniacal  when 
voided  indicates  chronic  vesical  catarrh  or  obstructive 
disease  of  the  bladder  or  ureters. 

When  the  urine  is  mixed  with  blood  or  pus '  the  re- 
action is  generally  alkaline.  The  administration  of 
mineral  acids  gives  the  urine  a  strongly  acid  reaction. 

Specific  Gravity. — The  specific  gravity  of  urine  in 
health  varies  from  1015  to  1025.  When  the  quantity 
of  urine  is  large  the  specific  gravity  is  low,  except  in 
diabetes  mellitus  ;  and  when  the  quantity  is  small  the 
specific  gravity  is  high. 

The  most  convenient  method  of  estimating  the  spe- 
1  In  pyelitis  and  pyelonephritis  the  reaction  is  acid. 


180 


PHYSICAL  DIAGNOSIS. 


cific  gravity  is  by  means  of  the  urinometer.  It  consists 
of  a  blown-glass  float,  weighted  with  mercury,  and  a 
graduated  stem  upon  which  the  readings  are  to  be 
made.  A  cylinder  of  convenient  size  is  nearly  filled 
with  the  urine  and  the  instrument  floated  in  it.  The 
reading  should  be  made  at  the  lowest  point  of  the  con- 
cave surface  of  the  urine. 

From  the  specific  gravity  of  urine  a  rough  estimate 
may  be  made  of  the  amount  of  solid  matter  contained 
in  solution.  The  method  was  proposed 
by  Trapp.  If  the  reading  is  below  1018 
the  last  two  figures  are  to  be  multi- 
plied by  2  ;  if  above,  by  2.33.  This  will 
give  the  amount  per  thousand  volumes. 
For  example,  in  1, 500  grammes  of  urine 
whose  specific  gravity  is  1030  there 
will  be  104.85  grammes  of  solid  mat- 
ter. If,  then,  the  quantity  of  urine 
voided  in  the  twenty-four  hours  be 
known,  the  daily  excretion  of  solids 
can  be  approximately  ascertained. 
In  disease  the  average  specific  gravity  of  the  urine 
may  be  increased  or  diminished.  It  is  highest  in  dia- 
betes, and  lowest  in  hysteria.  In  inflammations,  as 
pneumonia,  pleurisy,  etc.,  and  in  fevers,  it  often  rises 
as  high  as  1035.  On  the  other  hand,  when  the  average 
specific  gravity  is  abnormally  low  you  may  suspect  some 
exhausting,  non -inflammatory  complaint,  as  Bright's 
disease,  in  which  it  may  fall  so  low  as  1006.  As  a  rule, 
the  lower  the  average  specific  gravity  of  the  urine  in 
chronic  Bright's  disease,  the  more  unfavorable  the  prog- 
nosis. 

Character  of  Deposit. — The  deposit  may  be  scant 
or  heavy,  amorphous  or  crystallized,  white  or  colored. 


Fig.  21.— Urinometer. 


UREA.  181 

Deposits  of  urates  are  pink,  reddish  (brick-dust),  brown, 
or  white  in  color.  Uric  acid  crystals  form  a  scant  red- 
dish-brown sediment  resembling  grains  of  red  pepper. 
"When  pus  is  present  the  sediment  is  heavy  and  of  a  yel- 
lowish-white color.  Deposits  of  blood  are  reddish  in 
color.  Mucus,  when  present  in  large  amount,  forms  a 
heavy,  gelatinous  deposit. 

The  naked-eye  inspection  is  not  to  be  relied  upon. 
The  deposit  should  always  be  examined  chemically  and 
microscopically. 

Chemical  Characters. 

NORMAL   ELEMENTS. 

Urea  is  a  product  of  tissue  metabolism.  It  is  the 
chief  form  in  which  nitrogen  leaves  the  system.  The 
urea  which  passes  off  in  urine  is  brought  to  the  kidneys 
as  such  in  the  blood.  It  is  not  probable  that  the  kid- 
neys have  the  power  of  forming  urea  by  a  special  func- 
tion. The  amount  excreted  by  a  healthy  adult  is  about 
thirty  grammes  in  the  twenty-four  hours,  but  it  is  sub- 
ject to  great  variation,  being  dependent  upon  the 
amount  and  kind  of  food  eaten.  An  animal  diet  in- 
creases the  daily  excretion,  while  a  vegetable  diet  di- 
minishes it.  The  amount  excreted  is  not  affected  by 
exercise. 

Quantitative  Estimation  of  Urea. — A  convenient  ure- 
ometer  has  been  devised  by  Dr.  Charles  Doremus  for  the 
rapid  estimation  of  urea.  It  consists  of  a  closed  glass 
tube  bent  into  two  arms  ;  the  long  arm  is  graduated,  the 
short  arm  is  dilated  into  a  bulb  (see  Fig.  22).  Sodium 
hypobromite  is  the  reagent  employed.  "When  urea  is 
brought  in  contact  with  sodium  hypobromite,  it  is  de- 
composed and  nitrogen  gas  is  given  off.  The  solution 
is  made  by  adding  one  cubic  centimetre  of  bromine  to 
ten  cubic  centimetres  of  a  solution  of  sodium  hydrate 


182 


PHYSICAL   DIAGNOSIS. 


(one  hundred  grammes  to  two  hundred  and  fifty  cubic 
centimetres  of  water),  and  diluting  with  ten  cubic  centi- 
metres of  water.  It  should  be  freshly  prepared  for  each 
examination,  as  it  deteriorates  on  keeping. 

The  method  of  using  the  instrument  is  as  follows  : 
Fill  the  ureometer  to  the  mark  =  with  the  sodium  hy- 
drate solution,  add  one  cubic  centimetre  of  bromine  by 
means  of  the  pipette,  and  pour  in  sufficient  water  to  fill 

the  long  arm  and  bend. 
Wash  the  pipette,  and 
then  draw  up  one  cubic 
centimetre  of  the  urine 
to  be  tested.  Introduce 
the  tip  of  the  pipette  well 
into  the  bend,  and  force 
the  urine  out  gradually. 
As  it  passes  into  the  hy- 
pobromite  solution,  ni- 
trogen gas  is  evolved  and 
collects  at  the  top  of  the 
tube.  The  reading  is 
made  after  twenty  min- 
utes. Each  division  of 
the  scale  indicates  0.001. 
gramme  of  urea  for  one 
cubic  centimetre  of  urine.  If,  then,  the  number  of  mil- 
ligrammes to  the  cubic  centimetre  be  multiplied  by  the 
number  of  cubic  centimetres  of  urine  passed,  the  result 
will  be  the  amount  of  urea  excreted  in  twenty-four 
hours.  If  the  percentage  by  volume  be  desired,  multiply 
the  number  of  milligrammes  found  by  one  hundred. 

As  the  amount  of  urea  excreted  at  different  times  of 
the  day  varies,  the  specimen  to  be  examined  should  be 
taken  from  the  mixed  urine  of  twenty-four  hours. 


Fig.  22.— Ureometer. 


URIC    ACID.  183 

Clinical  Significance. — In  disease,  the  quantity  of 
urea  contained  in  the  urine  may  be  abnormally  increased 
or  strikingly  diminished.  It  is  abnormally  increased  in 
all  febrile  affections  (except  yellow  fever),  in  all  nervous 
affections  (especially  in  epilepsy;,  in  pyaemia,  in  diabetes, 
and,  as  a  rule,  in  acute  inflammation  of  the  thoracic 
viscera.  It  is  abnormally  diminished  in  cholera,  in  some 
cases  falling  as  low  as  four  grammes  in  twenty-four 
hours. 

In  Bright' s  disease,  the  diminution  in  the  quantity  of 
urea  in  the  urine  is  marked  and  significant.  As  a  rule, 
the  more  albumin  in  the  urine  the  less  the  amount  of 
urea,  and  vice  versa.  But  not  infrequently,  in  patients 
with  waxy  or  cirrhotic  kidneys,  the  quantity  of  albu- 
min may  be  slight,  or  for  a  time  entirely  absent 
(the  urine  being  of  low  specific  gravity),  and  still  the 
quantity  of  urea  daily  excreted  falls  far  below  the  nor- 
mal standard.  In  all  forms  and  stages  of  those  kidney 
changes  included  under  the  term  Bright's  disease,  it  is 
important  to  determine  accurately  the  quantity  of  urea 
contained  in  each  day's  urine — it  is  not  only  an  impor- 
tant element  in  diagnosis,  but  also  in  prognosis. 

Uric  Acid  is  a  normal  constituent  of  the  urine.  It  is 
not  present  as  the  free  acid,  but  in  combination  as 
urates.  The  daily  excretion  of  uric  acid  varies  from  0.5 
to  1  gramme.  Like  urea,  it  is  a  product  of  tissue 
metamorphosis',  and  is  increased  by  an  animal  diet. 
Its  proportion  to  urea  is  as  1: 45. 

The  presence  of  free  uric  acid  is  detected  by  the  murex- 
ide  test.  Place  the  suspected  deposit  in  a  small  crucible 
with  a  few  drops  of  nitric  acid,  and  evaporate  nearly  to 
dryness.  On  the  addition  of  a  drop  of  ammonia  a  rich 
purple  color  is  produced.  (For  the  microscopical  exam- 
ination see  page  217.) 


184  PHYSICAL   DIAGNOSIS. 

To  estimate  the  quantity  of  uric  acid  in  a  specimen  of 
urine,  add  one  part  of  hydrochloric  acid  to  twenty  parts 
of  the  urine,  and  set  it  aside  for  a  day  or  two.  The 
uric  acid  in  the  bases  is  replaced  by  the  hydrochloric, 
and  thrown  down  as  yellowish  or  brownish  crystals. 
These  should  be  carefully  separated,  dried,  and  weighed. 
The  calculation  is  then  made  for  the  urine  of  twenty- 
four  hours. 

Urates. — The  urates  found  in  the  urine  are  chiefly 
those  of  sodium  and  ammonium.  In  perfectly  healthy 
urine  they  are  held  in  solution.  Sometimes,  however, 
when  the  amount  of  water  is  diminished,  as  after  exces- 
sive perspiration,  they  are  precipitated  as  the  urine 
cools.  The  deposition  of  urates  usually  occurs  in  strong- 
ly acid  urine  of  high  specific  gravity.  They  form  a 
heavy  deposit,  of  a  pink,  reddish,  brown,  or  even  white 
color.     Urates  are  readily  dissolved  by  heat. 

Clinical  Significance. — Uric  acid  is  not  always  in 
excess  when  it  is  readily  precipitated.  If  the  urine 
is  very  acid,  it  may  be  separated  from  its  bases  and 
thrown  down.  This  may  occur  before  the  urine  is 
voided,  and  be  the  basis  of  the  formation  of  calculi. 

The  amount  of  uric  acid  excreted  is  diminished  in  an- 
aemia, chlorosis,  and  the  advanced  stages  of  Bright's  dis- 
ease. It  is  increased  in  those  diseases  of  the  heart  and 
lungs  where  there  is  deficient  aeration  of  the  blood,  in 
many  diseases  of  the  liver,  in  fevers,*  and  in  acute 
rheumatism. 

The  urates  are  frequently  separated  with  the  uric  acid. 
Persons  who  habitually  pass  urine  containing  deposits 
of  urates  and  uric  acid  are  generally  the  subjects  of  gas- 
tric and  hepatic  disorders.  They  are  usually  large  eaters 
and  drinkers,  and  take  little  exercise.  Deficient  oxida- 
tion is  the  chief  cause  of  the  uric  acid  diathesis. 


CHLORIDES.  185 

Phosphates. — The  normal  quantity  of  phosphates  ex- 
creted in  twenty-four  hours  has  been  found  to  be  about 
2.5  grammes.  They  are  derived  in  part  from  the  food, 
and  in  part  from  tissue  metabolism — some  have  sup- 
posed, principally  the  nervous  tissues.  Phosphates  of 
sodium,  calcium,  and  magnesium  are  the  salts  present  in 
largest  amount.  The  calcium  and  magnesium  salts  con- 
stitute the  earthy  phosphates.  As  long  as  the  urine  is 
acid  in  reaction,  the  phosphates  are  held  in  solution. 
Sometimes,  however,  calcium  phosphate  is  precipitated 
upon  the  application  of  heat.  In  alkaline  fermentation, 
urea  is  decomposed  by  a  special  bacterium,  with  the  for- 
mation of  ammonium  carbonate  ;  the  earthy  phosphates 
are  precipitated,  and  in  the  presence  of  ammonia  the 
triple  phosphate  crystals  are  formed  (see  page  218). 

Deposits  of  phosphates  are  readily  dissolved  by  a  few 
drops  of  nitric  acid.  The  phosphates  are  not  always  in 
excess  when  they  are  readily  precipitated ;  and,  on  the 
other  hand,  they  may  be  in  excess  and  yet  remain  in 
solution.  They  are  increased  in  amount  by  a  proteid 
diet  and  by  mental  or  bodily  exercise. 

Clinical  Significance. — Like  most  urinary  ingredients, 
the  quantity  of  phosphates  eliminated  in  the  urine  un- 
dergoes a  marked  change  in  disease.  It  has  been  found 
to  be  abnormally  increased  in  all  inflammatory  diseases 
of  the  nervous  system,  in  paralysis,  or  any  severe  nerve 
lesion,  in  acute  mania,  delirium  tremens,  and  in  rickets. 
It  is  diminished  in  most  febrile  and  inflammatory  affec- 
tions, especially  pneumonia  (unless  nerves  or  nerve  cen- 
tres are  involved),  in  Bright's  disease,  in  gout,  and  in 
rheumatism. 

Chlorides. — Sodium  chloride  is  the  only  chloride  pre- 
sent in  the  urine  in  sufficient  amount  to  claim  attention. 
The  mean  daily  excretion   has  been  computed  at  11.5 


186  PHYSICAL  DIAGNOSIS. 

grammes.  But  as  it  is  derived  chiefly  from  the  food,  it 
is  subject  to  great  change. 

The  test  for  sodium  chloride  consists  in  acidulating  the 
urine  with  a  drop  or  two  of  nitric  acid,  and  the  addition 
of  a  little  silver  nitrate  solution.  The  chloride  of  silver 
is  formed,  which  is  insoluble  in  nitric  acid,  but  readily 
soluble  in  ammonia. 

Clinical  Significance  of  Chloride  of  Sodium. — An  in- 
crease of  the  chlorides  in  the  urine  in,  disease  is  rarely,  if 
ever,  met  with,  and  has  no  clinical  significance  ;  but 
their  diminution  or  absence  is  of  so  frequent  occurrence 
in  certain  forms  of  disease  as  to  become  an  important 
aid  in  their  diagnosis.  Their  absence  is  most  marked 
and  constant  in  the  exudative  stage  of  acute  inflamma- 
tion, especially  in  pneumonia  during  the  stage  of  hepati- 
zation, when  they  may  be  absent  for  two  or  three  days, 
but  return  as  soon  as  resolution  commences.  They  are 
often  absent  in  fevers,  especially  in  typhus.  In  acute 
rheumatism,  as  soon  as  the  endocardium  and  pericar- 
dium become  implicated  they  generally  suddenly  disap- 
pear. Chloride  of  sodium  is  absent  or  diminished  in 
cholera,  and  its  increase  or  return  is  regarded  a  very 
favorable  symptom. 

The  Sulphates  are  present  in  urine  in  large  quantities. 
They  are  chiefly  those  of  potassium  and  sodium,  the 
former  being  present  in  greater  amount.  The  test  for 
the  sulphates  consists  in  adding  a  drop  or  two  of  nitric 
acid  and  a  few  drops  of  a  saturated  solution  of  barium 
chloride  to  some  of  the  urine.  A  white  precipitate,  in- 
soluble in  acids,  is  formed. 

An  increased  or  diminished  excretion  of  sulphates  has 
little  bearing  clinically.  They  are  generally  increased  in 
acute  febrile  affections  when  large  quantities  of  urea  are 
excreted. 


ALBUMIN.  187 

Abnormal  Elements. 

ALBUMIN. 

Of  the  different  forms  of  albumin  which  have  been 
found  in  urine,  serum-albumin  is  the  one  which  at  pre- 
sent has  most  clinical  significance.  Numerous  tests 
have  been  proposed  for  its  detection,  but  only  three  of 
them  will  be  considered  here. 

Before  applying  a  test  the  urine  should  be  rendered 
clear  by  filtration.  When  the  turbidity  is  due  to  a  de- 
posit of  urates,  a  gentle  heat  will  suffice  to  remove  it. 

Qualitative  Tests.  1.  Heat  and  Nitric  Acid. — Pour 
the  urine  into  a  test  tube  until  it  is  about  three-quarters 
full,  and  boil  the  upper  portion  of  it — the  lower  portion 
is  used  for  comparison.  If  a  precipitate  forms,  it  may  be 
due  to  the  presence  of  albumin  or  to  an  excess  of  phos- 
phates— the  addition  of  a  few  drops  of  nitric  acid  will 
decide  which.  A  precipitate  of  phosphates  is  readily 
dissolved,  while  albumin  is  not  affected  or  increased  in 
amount. 

2.  Heller's  Test. — Pour  a  small  quantity  of  nitric  acid 
into  a  narrow  test  tube  ;  draw  some  of  the  urine  into  a 
pipette  and  float  it  on  the  surface  of  the  acid.  If  albu- 
min is  present,  a  clearly  defined  white  band  is  formed  at 
the  junction  of  the  two  liquids.  An  excess  of  urates 
will  likewise  give  a  white  band,  but  the  upper  border  is 
not  clearly  defined,  and  it  is  dissolved  by  the  application 
of  a  gentle  heat. 

This  test  is  very  accurate.  But  a  color  band  formed 
at  the  junction  of  the  two  liquids  must  not  be  mistaken 
for  albumin. 

3.  Potassium  Ferrocyanide  and  Acetic  Acid  Test. — 
Mix  some  of  the  urine  in  a  test-tube  with  an  excess  of 
acetic  acid,  and  add  a  few  drops  of  a  ten-per-cent  solu- 


188 


PHYSICAL   DIAGNOSIS. 


M 


tion  of  potassium  f  errocyanide.  In  the  presence  of  albu 
min  a  precipitate  will  form  ;  or,  if  the  amount  be  small, 
only  a  slight  turbidity  will  appear. 

It  is  especially  necessary,  in  applying  this  test,  to  have 
the  urine  clear,  otherwise  the  presence  of 
a  small  quantity  of  albumin  will  be  over- 
looked. 

Albumin  will  be  found  in  urine  that  is 
contaminated  with  blood,  pus,  or  the  men- 
strual discharge. 

Quantitative  Estimation. — The  albumi- 
nometer  gives  only  an  approximate  result, 
but  it  is  sufficiently  accurate  for  clinical 
purposes.  It  consists  of  a  thick  glass  cyl- 
inder the  shape  of  a  test  tube  (see  Fig. 
23).  At  its  upper  portion  is  the  mark  R  ; 
about  midway,  down  the  mark  U  ;  and  be- 
low this,  a  graduated  scale. 

The  reagent  used  is  made  by  dissolving 
one  gramme  of  picric  acid  and  two  grammes 
of  citric  acid  in  one  hundred  cubic  centi- 
metres of  distilled  water. 

The  urine  is  poured  in  to  the  mark  U,  and 
the  reagent  added  to  the  mark  R.  The 
mouth  of  the  instrument  is  closed  with  a 
rubber  stopper  and  the  two  liquids  thor- 
oughly mixed  by  shaking.  It  is  then  set 
aside  in  the  upright  position  for  twenty-four 
hours. 

The  albumin  is  coagulated  and  falls  to  the  bottom. 
The  quantity  present  is  read  off  on  the  scale,  each  divi- 
sion of  which  corresponds  to  0.1  per  cent. 

1  When  the  exact  amount  is  desired,  the  albumin  must  be  coagu- 
lated, separated  by  filtration,  and  the  precipitate  dried  and  weighed. 


Fig.  S3. 


SUGAR.  189 

Clinical  Significance  of  Albumin  in  the  Urine. — 
When  albumin  is  found  in  the  urine,  the  first  and  im- 
portant question  to  decide  is,  whether  it  indicates  the 
existence  of  organic  disease  of  the  kidneys.  This  ques- 
tion may  be  decided  by  the  temporary  or  permanent 
duration  of  the  albuminuria,  by  the  quantity  of  the  al- 
bumin present,  and  by  the  presence  or  absence  of  any 
other  disease  which  might  give  rise  to  it. 

The  following  are  the  principal  pathological  scates  in 
which  albumin  appears  constantly  or  occasionally  in  the 
urine  : 

1.  Acute  and  chronic  diseases  of  the  kidney. 

2.  Acute  infectious  diseases. 

o.  Obstructed  venous  circulation,  either  general  or 
local. 

In  the  first  group  the  albumin  in  the  urine  depends  on 
structural  changes  in  the  kidneys.  In  the  other  groups, 
structural  changes  in  the  kidneys  are  not  necessarily  in- 
dicated by  the  albuminuria,  but  rather  some  abnormal 
condition  of  the  circulation  or  of  the  circulating  fluid. 

SUGAR. 

Various  forms  of  sugar  have  been  found  in  the  urine, 
but  grape  sugar  is  the  only  one  which  possesses  clinical 
interest.  It  is  not  present  in  normal  urine  in  sufficient 
quantity  to  respond  to  the  ordinary  tests. 

Urine  containing  sugar  is  usually  light  in  color,  of 
peculiar  odor,  and  with  a  specific  gravity  varying  from 
1025  to  1045.  If  albumin  is  present,  it  must  be  coagu- 
lated and  removed  by.  filtration  before  examining  for 
sugar. 

The  qualitative  tests  most  conveniently  applied  are 
Trommer's,  Fehling's,  and  the  Fermentation  Test. 

Trommer's  Test. — Pour  a  small  quantity  of  the  urine 


190  •     PHYSICAL    DIAGNOSIS. 

into  a  test  tube  and  add  about  one-third  its  volume  of 
liquor  potassse.  A  ten-per-cent  solution  of  copper  sul- 
phate is  now  added,  drop  by  drop,  until  no  more  will 
dissolve.  The  mixture  is  then  heated.  If  the  urine 
contains  sugar,  a  reddish-brown  precipitate  of  copper 
suboxide  is  thrown  down. 

This  test  is  not  always  reliable,  for  chloral,  uric  acid, 
and  bile  pigment  give  the  same  reaction. 

Feliling's  Test. — The  reagent  employed  consists  of 
two  solutions — a  copper  solution  and  an  alkali  solution 
— which  should  be  kept  separate  in  well-stoppered  bot- 
tles, and  mixed  when  required.  The  copper  solution  is 
made  by  dissolving  34. 64  grammes  of  pure  crystallized 
copper  sulphate  in  one  hundred  cubic  centimetres  of 
water  and  diluting  to  five  hundred  cubic  centimetres  ; 
the  alkali  solution,  by  dissolving  one  hundred  and 
seventy  three  grammes  of  sodium  tartrate  and  one  hun- 
dred grammes  of  caustic  soda,  of  a  specific  gravity  of 
1034,  in  five  hundred  cubic  centimetres  of  water. 
Equal  parts  of  these  solutions  should  be  mixed  when 
required  for  use. 

In  applying  the  test,  pour  two  or  three  cubic  centime- 
tres of  the  reagent  into  a  test  tube,  and  heat  to  the  boil- 
ing point.  (If  a  precipitate  occurs,  the  reagent  is  use- 
less.) Add  an  equal  volume  of  urine  and  boil  again. 
If  sugar  is  present,  a  reddish-brown  precipitate  is 
formed. 

Fermentation  Test. — Fill  a  large  test  tube  with  the 
suspected  urine,  then  add  a  small  quantity  of  yeast, 
close  the  mouth  of  the  tube  with  the  finger,  and  invert 
it  in  a  tumbler  containing  a  considerable  quantity  of 
the  same  urine  ;  remove  the  finger  without  permitting 
air  to  enter  the  tube,  and  support  it  in  an  upright  posi- 
tion by  means  of  a  small  wire  triangle.     Set  the  appara- 


SUGAR.  191 

tus  in  a  warm  place  for  twenty-four  hours.  If  sugar  be 
present,  it  will  be  decomposed  by  fermentation  into  alco- 
hol and  carbon  dioxide,  the  gas  rising  to  the  top  of  the 
tube  and  displacing  the  urine  ;  if  sugar  be  absent,  no 
displacement  will  occur.  This  test  is  reliable,  provided 
the  yeast  is  good  and  the  temperature  suitable. 

Quantitative  Estimation. — The  urine  used  should 
be  taken  from  that  of  the  twenty-four  hours. 

Five  centigrammes  of  sugar  will  reduce  ten  cubic  cen- 
timetres of  Fehling's  fluid  prepared  as  above.  In  mak- 
ing the  estimate,  proceed  as  follows  : 

Ten  cubic  centimetres  of  the  fluid  are  diluted  with 
forty  cubic  centimetres  of  water,  and  placed  in  a  floren- 
tine  flask.  A  burette  is  filled  with  some  of  the  urine, 
diluted  with  nine  parts  of  water.  The  flask  is  put  upon 
a  tripod,  and  the  fluid  boiled.  A  little  of  the  urine  is 
added  from  time  to  time  until  the  light  blue  color  is 
lost.  It  is  well  to  remove  the  flask  after  each  addition 
of  urine,  and  examine  it.  Just  when  the  color  disap- 
pears is  a  nice  point  to  decide,  and  upon  it  depends  the 
accuracy  of  the  test.  The  amount  of  diluted  urine  used 
is  now  read  off.  Suppose  that  the  quantity  is  ten  cubic 
centimetres.  Now,  if  ten  cubic  centimetres  of  dilute 
urine  contain  0.05  gramme  of  sugar,  then  one  hundred 
cubic  centimetres  would  contain  0.5  gramme,  and  one 
hundred  cubic  centimetres  of  the  undiluted  urine  would 
contain  five  grammes,  or  five  per  cent  of  sugar. 

In  diabetes  mellitus  the  percentage  of  sugar  varies 
from  a  minimum  of  one-half  per  cent  to  a  maximum  of 
ten  per  cent. 

The  fermentation  saccharometer  of  Max  Einhorn  gives 
approximately  the  amount  of  sugar  contained  in  a 
specimen  of  urine.  It  is  based  on  the  principle  that,  in 
alcoholic  fermentation,  for  a  given  quantity  of  sugar  so 


192 


PHYSICAL  DIAGNOSIS. 


much  carbon  dioxide  is  evolved.  The  apparatus  is 
shown  in  the  accompanying  cut.  The  method  of  using 
it  is  as  follows  :  Shake  one  gramme  of  commercial  com- 
pressed yeast  with  ten  cubic  centimetres  of  the  urine  to 
be  examined,  in  a  test  tube,  and  fill  the  long  arm  of  the 
instrument  with  the  mixture.  Set  it  aside  for  twenty- 
four  hours  in  a  room  of  ordinary  temperature.  As  the 
carbon  dioxide  is  given  off  it  rises  to  the  top  and  dis- 
places the  urine,  giving  the  percentage  of  sugar  present. 


Fig.  24  —  Saccharometer. 


If  the  urine  contain  more  than  one  per  cent  of  sugar, 
it  must  be  diluted  with  water  and  again  tested.  The 
degree  of  dilution  must  be  taken  into  account  in  mak- 
ing the  reading. 

In  applying  this  test,  it  is  well  to  perform  a  control 
experiment  with  normal  urine  in  order  to  prove  the 
purity  of  the  yeast.  Fill  a  test  tube  with  the  urine  and 
thoroughly  mix  a  little  of  the  yeast  with  it.  Then 
invert  the  tube  in  a  tumbler  containing  some  of  the 
same  urine.    If  the  yeast  is  pure,  after  twenty-four  hours 


BILE.  193 

there  will  be  no  accumulation  of  gas  at  the  top  of  the 
tube,  but  perhaps  a  small  bubble  of  air  may  be  seen. 

Clinical  Significance. — The  presence  of  sugar  in  the 
urine  indicates  that  there  is  an  excess  in  the  blood. 
It  may  occur  temporarily  and  in  small  quantity  (glyco- 
suria), or  continually  and  in  large  quantity  (diabetes 
mellitus).  Persons  who  confine  themselves  largely  to  a 
carbohydrate  diet  may  occasionally  have  sugar  in  their 
urine.  It  is  almost  constantly  present  during  convales- 
cence from  acute  infectious  diseases,  such  as  typhus 
fever,  diphtheria,  pneumonia,  etc. 

In  lesions  of  certain  parts  of  the  central  nervous  sys- 
tem, sugar  is  found  in  the  urine  :  injury  to  the  medulla 
gives  rise  to  a  diabetes  which  may  last  for  a  considerable 
time. 

Glycosuria  follows  poisoning  by  carbon  dioxide  and 
the  administration  of  ether  or  chloroform.  Gouty  pa- 
tients are  subject  to  glycosuria  at  intervals. 

BILE. 

When  bile  is  present  in  the  blood,  it  is  excreted  by 
the  kidneys.  It  imparts  a  dark  olive-green  tint  to  the 
urine.  Gmelin's  test  for  the  bile  pigments  consists  in 
placing  a  drop  of  the  urine  on  a  white  surface  and  a 
drop  of  fuming  nitric  acid  alongside  of  it.  As  the  two 
come  in  contact  a  beautiful  play  of  colors  is  observed, 
commencing  with  green  and  blue,  changing  rapidly  to 
violet  and  red,  and  finally  to  yellow  or  brown. 

The  presence  of  biliary  acids  can  be  demonstrated  by 
Pettenkofer's  test.  Add  a  few  drops  of  a  weak  solution 
of  cane  sugar  to  a  little  of  the  urine  in  a  porcelain  cap- 
sule. Place  the  capsule  in  cold  water.  Now  add  an  ex- 
cess of  concentrated  sulphuric  acid,  drop  by  drop,  taking 
care  that  the  temperature  is  not  raised  above  70°  C.     A 

13 


194  PHYSICAL  DIAGNOSIS. 

beautiful  violet  color  indicates  the  presence  of  the  bile 
acids. 

In  cases  of  jaundice  the  bile  coloring  matter  or  the 
biliary  acids  are  present  in  the  urine  in  greater  or  less 
abundance. 

BLOOD. 

The  blood  cells  may  be  present  in  the  urine  (haematu- 
ria),  or  only  their  coloring  matter  in  solution  (haemo- 
globinuria).  Blood  may  be  intimately  blended  with  the 
urine,  and  form  little  or  no  sediment.  Urine  containing 
blood  is  generally  alkaline  in  reaction,  and  of  a  light 
smoky  to  a  deep-red  color.  The  most  reliable  test  for 
blood  is  that  furnished  by  the  spectroscope.  (For  the 
microscopical  examination,  see  lesson  on  Clinical  Micro- 
scopy.) Haemoglobin  produces  two  characteristic  ab- 
sorption bands  in  the  yellow  and  green  between  the 
lines  D  and  E.  If  it  is  reduced  haemoglobin,  only  one 
broad  band  is  seen. 

The  guaiacum  test  consists  in  adding  a  drop  of  the 
tincture  of  guaiacum  and  a  few  drops  of  ozonic  ether 
to  a  little  of  the  urine  in  a  test  tube.  The  mixture  is 
shaken,  and  then  the  ether  allowed  to  collect  at  the  top. 
If  blood  be  present,  the  ether  will  have  a  blue  color. 
The  test  cannot  be  relied  upon  in  the  presence  of  saliva 
or  the  salts  of  iodine,  or  unless  the  tincture  is  freshly 
prepared. 

Blood  occurs  in  the  urine  after  injury  to  any  part  of 
the  genito-urinary  tract,  in  acute  congestion  and  in- 
flammation of  the  kidneys,  as  a  result  of  poisoning  by 
carbolic  acid,  in  cancer  of  the  bladder,  and  in  acute 
infectious  diseases,  such  as  small-pox,  yellow  fever,  etc. 
It  is  present  in  malaria,  scurvy,  purpura,  and  haemo- 
philia. 


PUS.  195 

PUS. 

Pus  in  the  urine  (pyuria)  forms  a  heavy  white  or  yel- 
lowish sediment,  and  the  liquid  above  is  generally  tur- 
bid. The  urine  is  alkaline  in  reaction,  except  in  cases 
of  pyelitis  and  pyelonephritis,  where  it  is  acid.  Owing 
to  the  alkalinity,  the  phosphates  are  quickly  thrown 
down.  It  is  common  to  find  the  earthy  phosphates  and 
crystals  of  ammonio-magnesium  phosphate  associated 
with  the  pus  cells  (see  page  221),  in  which  case  the  urine 
has  an  ammoniacal  odor. 

When  sodium  hydrate  is  added  to  a  deposit  of  pus,  a 
thick,  gelatinous  mass  is  formed.  But  the  test  is  not 
accurate.  The  presence  of  pus  cells  should  always  be 
demonstrated  by  a  microscopical  examination. 

In  cystitis  an  abundance  of  mucus  is  usually  mixed 
with  the  pus. 

Pyuria  indicates  suppuration  somewhere  in  the  genito- 
urinary tract.  It  occurs  in  pyelonephritis,  pyelitis,  in 
cystitis,  and  in  gonorrhoea.  Leucorrhceal  discharges 
often  contaminate  urine.  If  an  abscess  opens  into  the 
urinary  passages,  pus  suddenly  appears  in  the  urine  in 
large  quantity,  and  after  a  few  days  diminishes  in 
amount  or  ceases  altogether. 


CLINICAL  MICROSCOPY. 


LESSOR  XVIII. 

CLINICAL  MICROSCOPY — BLOOD,    SPUTUM,    URINE,    VOMIT, 

FJECES. 

Examination  of  the  Blood. 

For  clinical  purposes  the  microscopical  examination 
of  the  blood  is  restricted  to  determining  the  number  and 
condition  of  its  cellular  elements,  and  searching  for 
pathogenic  bacteria  and  animal  parasites.  To  obtain  a 
specimen  of  blood  for  examination,  the  tip  of  the  finger 
or  the  lobe  of  the  ear,  after  being  thoroughly  cleansed, 
is  pricked  with  a  needle,  a  slide  is  lightly  touched  to  the 
apex  of  the  drop  of  blood  pressed  out,  a  cover  glass  is 
immediately  placed  over  the  drop,  and  slight  pressure 
made  so  as  to  have  a  thin  layer  for  examination.  If  the 
specimen  cannot  be  examined  immediately  after  its  re- 
moval, a  small  amount  of  melted  paraffin  or  flexible 
collodion,  run  around  the  edge  of  the  cover  glass,  will 
keep  the  blood  unchanged  for  several  days.  To  prepare 
a  dried  specimen,  instead  of  covering  with  a  cover  glass, 
the  end  of  another  slide  is  lightly  drawn  across  the  first 
one,  spreading  out  the  drop  in  a  thin  layer,  which  is 
allowed  to  dry  spontaneously.  In  a  specimen  so  pre- 
pared the  corpuscles  are  likely  to  lose  their  true  form. 
When  normal  blood  is  examined  under  the  microscope, 
three  varieties  of  cells  are  noted. 

Red  Blood  Corpuscles  (Fig.  25). — These  appear  as 
flattened,  bi-concave  discs  with  a  diameter  of  0.007  milli- 


200 


PHYSICAL    DIAGNOSIS. 


metre.  When  the  centre  of  the  cell  is  in  focus,  the  outer 
rim  appears  dark ;  when  the  edge  is  in  focus,  then  the 
centre  appears  dark.  The  cells  show  a  tendency  to  ad- 
here to  each  other,  forming  rouleaux  or  coin  heaps. 
After  exposure  to  the  air  for  a  short  time,  they  lose  their 
normal  smooth  contour  and  the  periphery  becomes  un- 
even or  crenated. 

Blood  Plates. — These  are  small,  colorless,  ovoid  bod- 
ies, about  one-quarter  the  size  of  a  red  blood  corpuscle. 


Fig.  25.— Cellular  Elements  of  Human  Blood.  A,  red  blood  cells  forming  rouleaux ; 
B,  red  blood  cellscrenated  ;  D  and  E,  red  blood  cells  having  absorbed  water;  F  andG, 
red  blood  cells  with  surface  in  focus  ;  H,  white  blood  cells. 

White  or  Colorless  Corpuscles  (Fig.  25). — These 
appear  as  transparent  cells,  with  a  granular  protoplasm. 
They  are  mono-  or  multinucleated.  Their  size  varies 
from  that  of  the  red  blood  corpuscle  to  twice  its  size. 

Diminution  in  Number  of  Eed  Blood  Corpuscles 
(Oligocythcemia). — Normal  blood  contains  from  4,500,- 
000  to  5,000,000  red  blood  corpuscles  to  the  cubic  milli- 


BLOOD. 


201 


metre.  Iu  diseased  conditions  the  number  may  fall  to 
2,000,000,  and  in  extreme  cases  to  less  than  500,000. 
Marked  decrease  in  number  is  readily  detected  with  the 
aid  of  the  microscope  ;  the  field  is  more  transparent,  the 
color  of  the  corpuscles  is  paler, 1  they  show  their  bi-con- 
cave  form  less  characteristically,  and  the  rouleaux  are 
not  as  marked.  The  above  appearances  are  generally 
sufficient  for   diagnostic    purposes.     When     the    exact 


Fig.  26.— Blood  from  Case  of  Leucocythsemia.    A  A,  white  blood  corpuscles  ;  B  B, 
red  blood  corpuscles.    X  300. 

number     is    desired,   the  Thoma-Zeiss     or   some  other 
counting  apparatus  is  required. 

INCREASE  IN  THE  NUMBER  OF  WHITE  BLOOD  CORPUS- 
CLES (Leucocytosis). — The  proportion  of  white  to  red 
corpuscles  in  the  blood  varies  from  1 :  400-700.  Physio- 
logical increase  occurs  after  a  hearty  meal,  when  the 
ratio  may  be   raised  to  1 :  125.     In    diseased  conditions 


1  Oligocythaemia  is  usually  associated  with  deficiency  of  coloring 
matter. 

14 


202  PHYSICAL   DIAGNOSIS. 

(infectious  fevers,  affections  of  lymphatic  system,  etc.) 
the  colorless  corpuscles  are  temporarily  increased  in 
number. 

When  the  proportion  of  1  :  20  is  reached,  the  condition 
is  called  leucocythaemia  or  leukaemia  (Fig.  26).  In  ex- 
treme cases  the  colorless  corpuscles  equal  or  even  ex- 
ceed the  red  in  number. 

It  is  often  possible  to  determine  whether  the  disease  is 
of  the  lymphatic,  splenic,  or  myelogenic  type  by  observ- 
ing what  is  the  preponderating  character  of  the  leuco- 
cytes. When  small,  colorless  cells,  about  the  size  of 
a  red  blood  corpuscle,  with  a  single  nucleus  and  only 
a  faint  rim  of  surrounding  protoplasm  (lymphocytes), 
preponderate,  then  it  is  lymphatic.  If  larger  cells  alone 
are  found,  it  is  splenic.  "If  many  corpuscles  of  a  tran- 
sitional form  are  found,  nucleated  red  cells,  and  especial- 
ly large  white  multinuclear  corpuscles,  there  remains  no 
doubt  that  the  bone  marrow  is  the  seat  of  serious 
changes  and  the  disease  is  of  myelogenic  type  "  (Von 
Jaksch).  By  staining  a  dried  specimen  of  blood  with  a 
watery  solution  of  methyl  blue,  the  white  cells  are 
brought  out  more  distinctly. 

Changes  in  Size,  Form,  and  Color  of  Eed  Blood 
Corpuscles. — At  times  the  blood  contains  cells  that  are 
smaller  than  the  normal  red  blood  corpuscles,  but  which 
have  the  same  shape  and  contain  haemoglobin.  These 
cells  are  called  microcytes,  and  the  condition  micro- 
cythoemia.  It  occurs  in  all  forms  of  anaemia  and  has 
no  diagnostic  significance. 

Colored  corpuscles  that  are  larger  than  normal  (macro- 
cytes)  are  also  found,  and,  while  they  may  be  present  in 
all  anaemias,  they  are  most  common  in  the  pernicious 
type. 

Closelv   associated  with   variation  in  size  is   that   of 


BLOOD.  203 

form.  The  red  blood  corpuscle  may  assume  a  variety  of 
shapes,  as  club,  dumbbell,  anvil,  flask,  etc.,  when  they 
are  called  poikilocytes  (Fig.  27),  and  the  condition  poikilo- 
cytosis.  These  cells  are  found  in  varying  numbers  in  all 
anaemic  conditions,  but  are  most  marked  in  pernicious 
anaemia. 

As  the  color  of  the  red  blood  corpuscles  depends  upon 
the  amount  of  coloring  matter  they  contain,  a  pale  color 
of  the  blood  may  be  due  to  a  deficiency  of  haemoglobin, 
as  well  as  to  a  diminution  in  the  number  of  cells.  Both 
conditions  may  be  appreciated  under  the  microscope  with 


%■ — & 

*  h 

Fig.  27. — Poikilo-,  Macro-,  and  Microcy tes  (d,  6,  c) .    a,  normal  red  blood  cell ;  e,  broken- 
down  red  blood  cell ;  /,  nucleated  red  blood  cell  (marked  anaemia).    (After  Quincke  ) 

little  practice.  To  estimate  accurately  the  amount  of 
haemoglobin  in  the  blood,  Von  Fleischl's  haemometer  or 
Henocque's  haematoscope  is  required. 

Clinical  Significance  op  Blood  Changes. — The  diag- 
nostic value  of  changes  in  the  number  of  white  blood 
corpuscles  has  already  been  noted. 

In  simple  anaemia,  due  to  haemorrhage,  or  dependent 
upon  diseased  conditions  associated  with  a  diminution 
in  the  number  of  red  blood  corpuscles,  there  is  a  cor- 
responding decrease  in  the  amount  of  haemoglobin. 

In  chlorosis,  although   the  number  of  red  blood  cor- 


/ 


/ 


2(M 


PHYSICAL   DIAGNOSIS. 


puscles  is  not  notably  reduced,  the  loss  of  haemoglobin 
is  excessive,  and  the  individual  cells  appear  pale  and 
" washed  out."  Microcytes,  macrocytes,  and  poikilo- 
cytes  may  be  found  in  small  number. 

Pernicious  anaemia  is  attended  with  a  great  diminu- 
tion in  number  of  all  the  cellular  elements.  Individual 
macrocytes  may  be  found  that  have  an  excess  of  haemo- 
globin. Marked  poikilocytosis  almost  always  attends 
the  disease. 

Free  pigment,  and  white  blood  corpuscles  containing 


Fig.  88.— Spirillum  of  Relapsing  Fever.    QOrawn  by  J.  M.  Byron,  M.D.4  Loonois  Labo- 
ratory.    < 

pigment  granules,  are  found  in  the  melanaemi.a  of  mal- 
arial disease. 

At  the  present  time  a  few  micro-organisms  are  recog- 
nized in  the  blood  as  diagnostic  of  existing  diseased  con- 
ditions. 

Spirillum  of  Eelapsing  Fever.— To  examine  for 
spirilla  a  drop  of  blood  is  placed  on  a  slide  under  a  cover 
glass.  They  appear  as  fine,  delicate  spiral  threads.  Their 
length  is  about  six  times  the  diameter  of  a  red  blood 
corpuscle  (Fig.  28).     Attention  is  often  called   to  their 


BACILLUS   OF  ANTHRAX.  205 

presence  in  blood  by  the  disturbance  their  motion  causes 
in  the  red  blood  corpuscles.  They  should  be  sought  for 
with  an  oil-immersion  lens  and  Abbe's  condenser.     It  is 


/ 

/ 

\      M 

•  .  5  S 


Fig.  29.— Bacillus  of  Anthrax.    (Drawn  by  J.  M.  Byron,  M.D.,  Loomis  Laboratory.) 

almost  impossible  to  stain  them,  as  they  are  destroyed 
by  most  staining  solutions. 


a-x 


N 


\ 


Fig.  30.— Bacillus  of  Typhoid  Fever,     x  700.     (Drawn  by  J.  M.  Byron,  M.D.,  Loomis 
Laboratory.) 

Bacillus  of  Anthrax. — This  bacillus   appears  as  a 
rod,  straight  or  but  slightly  curved  ;  its  length  is  from 


206 


PHYSICAL    DIAGNOSIS. 


one  to  two  diameters  of  a  red  blood  corpuscle,  and  its 
breadth  about  one-sixth  its  length  (Fig.  29).  They  may 
be  joined  so  as  to  form  chains.     They  can  be  seen  with- 

L 


Fig.  31.— Plasmodium  Malarise.    (After  Delafield  and  Prudden.) 

out  staining,  or  can  be  stained  with  a  watery  solution 
of  methyl  blue  (two  parts  to  the  hundred).     Mice  and 


Fig.  32.— Filaria  Sanguinis  Hominis.    (Instantaneous  photograph  by  J.  M.  Byron,  M.D.) 

guinea-pigs  are  very  susceptible  to  this  disease.  If 
blood  from  a  case  of  anthrax  (wool-sorter's  disease)  be 
injected  into  one  of  these  animals,  they  show  immense 
numbers  of  bacilli  in  their  blood  in  a  short  time. 


SPUTUM.  207 

Bacillus  of  Typhoid  Fever  (Fig.  30). — This  bacillus 
lias  been  found  in  blood  aspirated  from  the  spleen.  (See 
also  Faeces.) 

Tubercle  Bacillus. — In  general  miliary  tuberculosis, 
tubercle  bacilli  are  sometimes  found  in  the  blood.  (For 
methods  of  staining,  etc.,  see  Sputum.) 

Plasmodium  Malaria. — Amoeboid  bodies  have  been 
found  in  the  blood  during  a  malarial  paroxysm  by 
Laveran  and  other  observers.  They  are  found  within 
the  red  blood  corpuscles  and  also  free  in  the  blood.  At 
times  they  show  pigment  granules.  They  stain  with 
methyl  blue  (Fig.  31). 

Filaria  Sanguinis  Hominis  (Fig.  32). — The  filaria  is 
found  in  the  blood  of  people  living  in  the  tropics,  or 
who  have  become  infected  there.  The  worm  may  give 
no  symptoms  beyond  the  urinary.  It  is  usually  absent 
from  the  blood  during  the  day. 

Examination  of  the  Sputum. 

CELLULAR  ELEMENTS. 

To  examine  for  cells,  a  small  portion  of  sputum  may 
be  put  on  a  slide  and  covered,  without  staining,  or  the 
specimen  maybe  double  stained  for  tubercle  bacilli,  when 
all  the  cellular  elements  except  red  blood  corpuscles  re- 
tain their  form. 

Epithelium.  —Squamous  cells  from  the  mouth  or  vocal 
cords  appear  as  large,  flat  cells,  more  or  less  granular. 
They  may  show  fissures  or  folds.  Columnar  epithelium 
from  trachea,  bronchi,  and  nose  is  less  often  present  ; 
rarely  are  the  cilia  seen. 

From  a  clinical  point  the  "alveolar"  cells  are  the 
most  important  variety  found  in  sputum.  They  are 
polygonal,  with  a  granular  protoplasm,  and  often  show 
granules   of  pigment  (carbon,  blood  pigment,  iron,  etc.) 


208 


PHYSICAL  DIAGNOSIS. 


or  fat  globules  ;  their  nuclei  are  made  more  distinct  by 
the  addition  of  acetic  acid.  The  statement  that  they  are 
the  true  alveolar  cells  is  now  questioned.  Their  presence 
indicates  that  the  specimen  of  sputum  is  from  deeper 
portions  of  the  respiratory  tract,  whatever  may  be  their 
origin. 

White  Blood  Cells  or  Pus  Cells. — These  are  always 
present  in  sputum.  When  an  abscess  ruptures  into  the 
lung,  or  in  purulent  bronchitis,  they  may  constitute  the 
entire  cellular  element.     They  give  the  characteristic  re- 


%M~J& 


Fig.  33. 


Fig.  34. 


Fig.  33. — Ourschmann's  Spirals,    a,  central  thread.    (After  Curschmann.) 
Fig.  34.— Bronchial  Cast. 


action  to  acetic  acid.  They  often  contain  particles  of 
pigment. 

Liver  cells  may  be  found  in  sputum.  They  indicate 
the  op  ening  of  an  hepatic  abscess  into  a  bronchus. 

Red  Blood  Corpuscles. — A  few  are  always  found. 
They  show  their  characteristic  appearance  (see  Blood), 
except  when  retained  in  the  bronchi  for  some  time, 
when  hsematoidin  crystals  may  be  present. 

Ourschmann's  Spirals  (Fig.  33). — These  can  often  be 
seen  by  the  naked  eye.  When  magnified  they  are  found 
to  consist  of  a  white  central  thread  covered  by  fine 


SPUTUM. 


209 


fibres  spirally  arranged.  They  occur  most  often  during 
asthmatic  paroxysms  and  in  capillary  bronchitis. 

Bronchial  Casts  or  Fibrinous  Coagula  (Fig.  34). 
— When  the  casts  are  of  large  size  they  are  readily  de- 
tected by  the  naked  eye.  Microscopic  forms  occur  in 
pneumonia.  In  plastic  bronchitis  "they  are  long,  and 
the  terminal  filaments  may  form  a  fine  network  in 
which  epithelium  and  blood  corpuscles  are  enclosed." 

Elastic  Tissue. — Elastic  fibres  occur  generally  in 
bundles,  but  they  may  retain  the  form  of  the  alveoli 
(Fig.  35).     They  vary  considerably  in  length  and  thick- 


Fig.  35.— Elastic  Tissue.    (After  Von  Jaksch.) 


ness,  are  curled,  and  have  dark  borders.  To  obtain 
these  fibres  free  from  mucus,  etc.,  the  sputum  is  put 
into  a  test  tube,  diluted  with  an  equal  bulk  of  water, 
and  ten  or  fifteen  drops  of  liquor  potassae  added.  The 
mixture  is  then  heated  below  the  boiling  point  for  a  few 
minutes,  and  thoroughly  shaken.  By  this  process  all 
the  cellular  elements  are  destroyed,  but  elastic  tissue 
and  micro-organisms  are  not  affected.  After  standing 
for  one  or  two  hours,  a  small  portion  of  the  sediment  is 
placed  on  a  slide,  covered,  and  examined.  The  presence 
of  elastic  fibres  merely  shows  that  destruction  of  lung 
is 


210  PHYSICAL  DIAGNOSIS. 

tissue  is  taking  place.  They  are  found  in  tuberculosis, 
bronchiectasis,  pulmonary  abscess,  and  occasionally  in 
pneumonia.  In  pulmonary  gangrene  the  fibres  are 
generally  destroyed  in  the  lung  by  the  ferments  that  are 
formed  in  that  disease. 

PATHOGENIC  BACTERIA. 

Tubercle  Bacillus. — In  collecting  the  sputum  it  is 
necessary  to  instruct  the  patient  to  expectorate  into  a 
clean  cup  or  wide-mouthed  bottle,  being  careful  to  save 
that  portion  which  is  raised  after  coughing.  Frequently 
specimens  are  sent  for  examination  that  contain  only 
the  secretion  from  the  pharynx  and  posterior  nares. 
The  diagnostic  value  of  such  sputum  is  of  course  n  il, 
unless  there  is  tubercular  ulceration  of  these  parts  also. 

Staining  Solutions. — A  number  of  solutions  have 
been  proposed,  and  special  advantages  claimed  for  each. 
The  following  give  satisfactory  results  and  are  the  most 
stable  : 

No.  1.  ZieM-Neelson  Fuchsin  Solution — 

Fuchsin1 1  part. 

Alcohol,  ninety-five  per  cent 10  parts. 

Carbolic  acid 5 

Water  (distilled) . . . : • 100     " 

-   Filter  and  keep  in  a  well-stoppered  bottle. 

No.  2.  For  Decolorizing — 

Xitric  acid 1  part. 

Water 3  parts. 


1  Two  kinds  of  fuchsin  are  in  the  market,  the  basic  and  acid.  As 
tubercle  bacilli  only  stain  with  the  aniline  dyes  in  alkaline  solu- 
tions, the  acid  fuchsin  is  worthless.  The  bright,  crystalline  fuchsin 
is  for  the  most  part  basic.     Acid  alcohol  also  destroys  the  solution. 


SPUTUM.  211 

'  No.  3.  For  Double  Staining — 

Methyl  green  or  methyl  blue 2  parts. 

Water 100     " 

Filter  and  keep  in  a  dark  bottle. 

Preparation  and  Staining  op  Specimen. — The  por- 
tions of  sputum  most  likely  to  contain  the  tubercle 
bacilli  are  the  small,  whitish,  opaque  masses.  One  of 
these  is  picked  up  with  a  clean  platinum  needle  or  steel 
pen  in  a  holder,  and  transferred  to  a  cover  glass.  An- 
other cover  glass  is  placed  over  it,  and,  after  pressing 
out  the  excess  of  sputum,  the  two  glasses  are  separated 
by  quickly  sliding  one  from  the  other.  A  thin  film 
remains  on  each  glass,  and  is  allowed  to  dry  spontane- 
ously. "When  dry,  the  cover  glass  is  passed  slowly 
through  the  flame  of  a  Bunsen  burner  or  alcohol  lamp 
three  or  four  times  to  fix  the  film,  so  that  it  will  not  be 
washed  off  during  the  necessary  manipulations.  Care 
must  be  taken  that  the  cover  glass  is  not  heated  too 
hot,  as  then  the  bacilli  lose  their  affinity  for  the  dye. 
Either  of  the  following  methods  may  be  employed  for 
staining  the  specimen,  but  the  second  will  be  found  more 
convenient  : 

I.  A  small  amount  of  solution  No.  1  is  put  into  a 
watch  crystal,  and  the  cover  glass  floated  on  it  with  the 
film  down.  The  crystal  is  held  over  a  flame  until  steam 
arises  (do  not  allow  the  solution  to  boil).  After  a  few 
minutes  the  cover  glass  is  removed,  and  the  excess  of 
dye  rinsed  off  in  clean  water.  It  is  then  submerged 
in  solution  No.  2  for  a  few  seconds,  and  immediately 
rinsed  in  another  vessel  of  water.  If  the  film  still 
retains  a  bright-red  color,  it  must  be  dipped  again  in 
No.  2  and  immediately  rinsed.  This  can  be  repeated 
until  it  shows  only  a  slight  pink  or  rose  tint.     If  this 


212  PHYSICAL   DIAGNOSIS. 

step  is  carried  too  far,  then  even  tubercle  bacilli  will  be 
decolorized  and  the  distinctive  test  destroyed. 

The  cover  glass  is  now  floated  for  about  a  minute, 
film  down,  on  solution  No.  3,  in  another  watch  crystal, 
and  the  excess  of  dye  washed  off  in  clean  water.  It  is 
then  ready  to  be  placed  on  a  slide  and  examined. 

II.  The  cover  glass,1  film  up,  is  seized  in  forceps  ; 
with  a  medicine  dropper  a  few  drops  of  solution  No.  1 
are  poured  upon  it,  and  heated,  by  slowly  passing 
through  the  flame  of  a  lamp  or  burner  several  times, 
until  steam  arises.  After  a  few  minutes  the  dye  is 
washed  off,  as  in  I.,  and  solution  No.  2  added.  This  is 
allowed  to  remain  for  a  few  seconds  only.  If  the  speci- 
men is  still  too  deeply  stained,  the  process  can  be  re- 
peated until  the  desired  rose  tint  is  obtained.  Lastly, 
a  few  drops  of  solution  No.  3  are  allowed  to  remain  on 
the  glass  for  about  a  minute.  This  should  be  washed 
off  in  clean  water.  The  preparation  can  be  dried  and 
permanently  mounted  in  Canada  balsam. 

The  tubercle  bacilli  can  be  detected  with  good  No.  7 
objective,  but  it  is  better  to  use  an  oil-immersion  lens 
and  Abbe's  condenser. 

The  tubercle  bacilli,  stained  red,  appear  as  small, 
rod-like  bodies,  slightly  curved.  While  individually 
they  are  about  one-quarter  the  diameter  of  a  red  blood 
corpuscle  in  length,  two  or  three  may  be  so  grouped  as 
to  appear  much  longer.     Spores  contained  in  them  do 

1  Instead  of  using1  cover  glasses  to  make  the  preparation,  a 
number  of  specimens  from  different  portions  of  the  sputum  can 
he  placed  on  a  slide,  which  is  then  treated  as  a  cover  glass,  except 
that  the  cedar  oil  is  placed  directly  on  the  film,  no  cover  glass  be- 
ing used. 

2  Self -retaining  forceps,  made  especially  for  this  purpose,  can  be 
obtained  from  dealers  in  microscopes  and  supplies. 


ACTINOMYCES. 


213 


not  stain,  but  are  seen  as  clear  spots,  giving  the  bacilli 
a  beaded  appearance  (Fig.  36). 

The  presence  of  bacilli  in  the  sputum  indicates  tuber- 
culosis of  the  lungs  or  larynx.  But  absence  of  the  ba- 
cilli does  not  indicate  that  there  is  no  tuberculosis,  un- 
less repeated  examinations  have  been  made.  In  acute 
miliary  tuberculosis  they  are  rarely  found. 

Actinomyces,  or  Ray  Fungus. — These  appear  as 
bunches  of  pear-shaped  bodies  (Fig.  37).    They  are  easily 


Fig.  3^.— Tubercle   Bacilli  from  Sputum.     X  900.     (Drawn  by  J.   M.  Byron,  M.D., 
Loomis  Laboratory.) 


detected  without  staining.  To  facilitate  the  examination, 
the  suspected  sputum  may  be  treated  with  liquor  potas- 
sae  (see  Elastic  Fibres  above),  and  the  actinomyces  looked 
for  in  the  sediment;  or  they  may  be  stained  by  Gram's 
method.  Their  presence  in  the  sputum  indicates  the 
involvement  of  the  lungs  by  this  disease,  whose  symp- 
toms and  early  physical  signs  are  similar  to  those  of 
tuberculosis. 

Pneumococcus  (Fig.  38). — The  pneumococci  of  Fried- 
lander  and  Frankel  are  found  in  the  sputum  in  croupous 


214  PHYSICAL   DIAGNOSIS. 

pneumonia.  Friedlander's  method  of  staining  them  is 
to  make  cover-glass  preparations  of  the  sputum,  as  in 
the  examination  for  tubercle  bacilli.    Treat  the  film  for 


Fig.  37.— Actinomyces,  or  Ray  Fungus,     X  850.    (Drawn   by  J.  M.  Byron,   M.D., 
Loomis  Laboratory.)  . 

a  minute  with  a   one-per-cent   solution  of  acetic   acid, 
after  which  the  specimen  is  allowed  to  dry  in  the  air  ; 


Fig.  38. — Pneumococcus.    (After  Von  Jaksch.) 

it  is  then  placed  for  a  few  seconds  in  a  saturated  aniline- 
water-and-gentian-violet  solution ;  finally  the  dye  is 
washed  off  with  water  and  the  cover  glass  mounted  on  a 


URINE.  215 

slide.  Frankel  treats  the  cover-glass  preparation  with 
a  weak,  watery  solution  of  methyl  blue.  Micro-organ- 
isms, morphologically  identical  with  the  pneumococcus, 
have  been  found  in  the  saliva  of  healthy  persons  and  in 
the  sputum  of  cases  of  bronchitis. 

Echixococctts. — Hooklets  and  portions  of  the  cyst 
wall  (Fig.  39)  are  found  in  the  spu-  ^s>»   *      *  v 

turn  when    hydatid   cysts    in    the      jA^^    /  ~^»  * 

*\,  0      *4  &     ' 
lungs,  pleura,  or  liver  have  ruptured        A    ^^r^  %  Sr?^ 

into  a  bronchus.  ^&\  7^  l^l. 

Amceb^;  Coli  may  be  found  in         tf7*^4^M#«d 

the  sputum  if   an  hepatic   abscess  ~*32  ^iJk§T°£o  j^ 

has  opened  up  through  the  lungs.         c~"°°    ^^ 

x  Fig.  89.— Echinococcus 

(See  Fig.  66.)  Hookiets. 

Urine. 
The  microscopical  examination  of  the  urine  deals  al- 
most exclusively  with  those  elements  that  form  the 
sediment.  The  urine  is  allowed  to  settle  in  a  conical 
glass  ;  after  a  few  hours  a  drop  of  the  sediment  is  re- 
moved with  a  pipette  and  placed  on  a  slide,  under  a 
cover  glass,  for  examination.  The  constituents  of  the 
sediment  may  be  divided  into  two  groups  :  1.  JSTon -or- 
ganized.    2.  Organized. 

I.    (a)  AMORPHOUS  DEPOSITS. 

Urates. — These  usually  appear  as  pale-pink,  brown, 
or  dark-red  granular  masses  (Fig.  40),  although  at  times 
the  urate  of  soda  has  a  globular  form  from  which  sharp 
spikes  of  uric  acid  project  (Fig.  -±1).  Urate  of  ammo- 
nia also  at  times  assumes  a  spherical  form,  with  or  with- 
out small  projecting  spicula  (Fig.  42). 

The  urates  are  held  in  solution  in  normal  urine  at  or 
slightly  below  the  body  temperature.  Their  precipita- 
tion is  favored  by  (a)  acidity,  (6)  concentration,  and  (c) 


21G 


PHYSICAL   DIAGNOSIS. 


cooling  of  the  urine.  They  appear  in  the  urine  in  dis- 
orders of  the  digestive  tract,  and  when  the  ingestion  of 
nitrogenous  food  is  beyond  the  needs  of  the  body ;  in 
febrile  conditions  ;  and  in  diseases  of  the  heart  and  lungs 
that  prevent  proper  oxygenation.  Too  little  exercise, 
close  rooms,  and  excessive  use  of  wine  and  malt  liquors 
predispose  to  their  appearance  in  the  urine.  Their  per- 
sistent presence  without  adequate  cause  is  one  of  the 
diagnostic  points  of  urinary  calculi. 


•B&Cter 


CM 


Fig.  40. 


Fig.  41. 


Fig.  42. 


Fig.  40.— Urate  of  Soda.    A,  amorphous  granules  in  clusters  ;  B,  granules  in  strings, 
sometimes  mistaken  for  granular  casts.    X  250. 

Fig.  41.— Urate  of  Soda  with  Spicula. 

Fig.  42.— Urate  of  Ammonia.    A,  clusters  of  brown  spherules  ;  B,  isolated  spherule 
with  spicula—"  the  chestnut-burr  "  crystals,    x  250. 


Calcium  Phosphate  and  Calcium  Carbonate. — 
These  are  found  in  alkaline  urine  only.  Calcium  phos- 
phate occurs  as  minute  granules  and  small  spherical 
masses  or  as  angular  particles.  Calcium  carbonate  is 
almost  always  amorphous.  Both  are  usually  associ- 
ated with  the  triple  phosphates. 

Fat. — When  fat  occurs  in  the  urine  in  small  quantity, 
the  condition  is  termed  lipuria.  The  urine  is  turbid,  but 
clears  up  on  shaking  with '  ether.  The  microscope  dis- 
closes globules  of  varying  size  which  strongly  refract 
light. 

In  chyluria,  fat  is  present  in  large  quantity  and  in  a 


URINE. 


317 


.U 


state  of  molecular  subdivision.  The  urine  has  a  milky 
appearance.  Chylous  urine  most  frequently  depends  on 
invasion  of  the  urinary  tract  by  the  Filaria  sanguinis 
hominis. 

(6)   CRYSTALLINE  DEPOSITS. 

Uric  Acid. — Crystals  of  uric  acid  assume  a  great  va- 
riety of  forms,  but  as  a  rule  they  can-be  recognized  by 
their  color  ;  the  lozenge-shaped  crystal  is  the  commonest 
form.  If  doubt  exists  as  to  the  nature  of  an  unusual 
form,  dissolve  the  crystals  by 
adding  a  drop  of  caustic  potash 
to  the  specimen,  and  then  acid- 
ulate with  a  little  hydrochloric 
acid  ;  if  they  are  uric  acid,  they 
will  recrystallize  in  one  of  the 
commoner  forms  (Fig.  43).  All 
crystals  of  uric  acid,  as  they 
appear  in  the  urine,  have  the 
characteristic  yellowish-red  col- 
or. 

Uric  acid  appears  in  the  urine 
under  the  same  conditions  that 
were  mentioned  for  urates,  with 
which  it  is  usually  associated. 
Deficient  action  of  the  skin,  from  any  cause,  produces  an 
excess  of  uric  acid  in  the  urine.  It  has  a  strong  tendency 
to  form  around  any  small  concretions  in  the  urinary 
tract,  giving  rise  to  uric  acid  calculi. 

Calcium  Oxalate. — This  is  generally  deposited  as 
small  octahedra  which  strongly  refract  light,  and  more 
rarely  in  the  hour-glass  or  dumbbell  form  (Fig.  44). 
"  The  prism  of  the  triple  phosphates  sometimes  appears 
octahedral,  and  the  diamond-shaped  crystals  of  uric  acid 
16 


Fig.  43.— Uric  Acid.  A,  the  most 
common  forms ;  B,  disintegrated 
crystals;  C,  formation  of  stellate 
masses. 


218 


PHYSICAL   DIAGNOSIS. 


are  occasionally  so  small  as  to  simulate  the  oxalates. 
Acetic  acid  dissolves  the  crystals  of  triple  phosphates, 
and  caustic  potash  causes  the  uric  acid  to  disappear, 
while  oxalate  of  lime  resists  both  reagents."  Crystals  of 
oxalate  of  lime  appear  in  the  urine  after  eating  apples, 
pears,  cauliflower,  and  the  different  varieties  of  sorrel, 

.  and  after  the  administration  of  rhu- 

'barb  ;  it  is  often  present  in  diabetes 
mellitus,  catarrhal  icterus,  gout,  hypo- 
chondria, and  after  epileptic  seizures. 
It  is  common  in  cases  of  mental  ex- 
haustion from  overwork  and  excite- 
ment. The  term  oxaluria  has  been  ap- 
plied to  that  condition  which,  in  addi- 
tion to  the  abundant  and  persistent  presence  of  calcium 
oxalate  crystals,  has  a  well-marked  train  of  nervous  and 
dyspeptic  symptoms  with  a  tendency  to  hypochondriasis. 
The  mere  finding  of  a  few  oxalate  of  lime  crystals  is  not 
sufficient  for  this  diagnosis. 


i  ^S4/ 


Fig.  44.  —  Calcium 
Oxalate,    x  250. 


Fig.  45.  Fig.  46. 

Figs.  45  and  45.—  Ammonio-Magnesium,  or  "Triple  "  Phosphates,     x  250. 

Ammonio-Magnesium,  or  "Triple"  Phosphates. — 
These  crystals  are  found  only  in  alkaline  urine.  During 
alkaline  fermentation,  urea  is  decomposed  with  the  for- 


URINE. 


219 


mation  of  ammonium  carbonate  ;  this  combines  with 
the  magnesium  phosphate  present  to  form  the  so-called 
triple  phosphate  crystals.  When  slowly  formed  the 
crystals  assume  the  shape  of  triangular  prisms  with 
bevelled  edges  (Fig.  46  A),  but  when  produced  rapidly 
they  have  a  feathery  outline  (Figs.  45  and  46  B). 

Calcium  Phosphate,  although  usually  amorphous, 
may  be  deposited  as  angular  crystals  (Fig.  47). 

The  precipitation  of  these  salts  in  crystalline  form 
does  no.t  necessarily  indicate  that  they  are  excreted  in 
excessive  quantities,  but  shows  that  there 
has  been  some  change  in  the  reaction  of 
the  urine,  due  to  alteration  in  some  of  its 
constituents  which  ordinarily  retain  these 
salts  in  solution.  Excessive  mental  work 
or  anxiety,  and  certain  forms  of  dyspepsia, 
reduce  the  acidity  of  the  urine  and  favor 
the  precipitation  of  the  earthy  phos- 
phates. Alkaline  fermentation  of  the  urine  in  the  uri- 
nary tract  causes  their  deposition  on  the  mucous  mem- 
brane and  the  subsequent  formation  of  calculi. 

Cystix.  — This  body  is  occasionally  found  in  the  urine 
in  crystalline  form;  it  occurs  as  six-sided 
plates  (Fig.  48). 

Little  is  known  of  the  conditions  that 
cause  its  elimination  by  the  kidneys. 
It  is  often  hereditary.  Brieger  has 
called  attention  to  the  relation  of  cer- 
tain ptomaines  in  the  intestinal  tract 
and  the  appearance  of  cystin  in  the  urine.  It  may  lead 
to  the  formation  of  calculi. 

Leucin,  Tyrosin. — The  urine  may  contain  large  quan- 
tities of  these  substances.  Leucin  appears  in  the  form 
of  spheres,  resembling  globules  of  fat  (Fig.  49).     When 


Fig.    47.— Calcium 
Phosphate. 


Fig.  48.— Cystin.    X  250. 


220 


PHYSICAL,  DIAGNOSIS. 


these  spheres  are  large  they  may  show  radiating  lines 
and  concentric  rings. 

Tyrosin  crystallizes  in  the  form  of  fine  needles  ar- 
ranged as  sheaves  (Fig.  50).  These  bodies  appear  in 
those  diseases  in  which  oxidation  is  impaired,  such,  as 
acute  yellow  atrophy  of  the  liver,  typhoid  fever,  small- 
pox, and  in  hepatic  diseases  generally. 

Xanthtn  rarely  occurs  in  the  urine.  It  is  of  interest 
clinically  only  as  it  may  form  calculi. 


Fig.  49.— Leucin.    X  250. 


Fig.  50.— Tyrosin.    X  250. 


II.    ORGANIZED. 

Mucus. — In  healthy  urine  it  is  almost  impossible  to 
detect,  microscopically,  the  small  amount  of  mucus  that 
is  present,  as  its  refractive  power  is  the  same  as  that  of 
the  urine.  When  it  holds  cells  or  crystals  its  presence 
may  be  inferred  from  the  arrangement  of  these  bodies. 
When  excessive  in  amount  it  is  often  seen  as  transpa- 
rent threads  or  cylindroids.  Pus  is  changed  by  alkaline 
fermentation  to  a  condition  that  resembles  mucus.  If 
small  mucus  threads  are  found  in  markedly  alkaline 
urine  with  an  ammoniacal  odor,  this  fact  must  be  con- 
sidered. 

Pus. — In  acid  urine  pus  cells  have  a  distinct,  circular 
outline,  the  protoplasm  is  granular,  and  the  nuclei  are 


URINE.  221 

more  or  less  apparent.  If  acetic  acid  is  allowed  to  flow 
under  the  cover  glass,  the  corpuscles  become  slightly 
enlarged,  they  lose  their  granular  appearance,  and  the 
nuclei  become  more  prominent  (Figs.  51  and  52).  If  the 
urine  has  undergone  marked  alkaline  fermentation,  the 
pus  cells  are  destroyed  (see  Mucus,  above). 

Pus1  in  the  urine  may  come  from  any  part  of  the  uri- 
nary tract,  or  from  the  rupture  of  an  abscess  into  it. 
When  its  origin  is  in  the  kidney,  the  normal  reaction  of 
the  urine  is  retained,  while  in  suppurative  inflammation 
of  the  bladder  the  reaction  is  alkaline  when  voided,  or 
it  soon  becomes  so.  The  epithelial  elements  associated 
with  the  pus  cells  often  decide  what  portion  of  the  tract 


Sg 

&■■  ?M -fin  cS"  **  ® """"( $ ) 

^Qm&  ^m  W  G\  fW*  _  •-" 


?'r;'  ?L  .%:  ■-(&  l 


Fig.  51.— Pus  Corpuscles.  Fig.  52.— Pus  Corpuscles  treated  with 

Acetic  Acid. 

is  involved.  In  women  the  accidental  contamination  of 
the  urine  with  pus  from  the  vagina  and  uterus  must  be 
considered.  Vaginal  epithelium  is  then  usually  present. 
The  distinctive  features  of  gonorrhceal  pus  will  be  con- 
sidered under  Micro-organisms  (page  226). 

Blood. — Eed  blood  corpuscles  are  recognized  by  their 
size,  color,  and  the  peculiar  change  of  light  and  shade  in 
focussing.     Frequently  they  become  globular  and  pale, 

1  Frequently  in  examining-  urine  a  very  few  corpuscles,  having 
all  the  appearances  of  pus  cells,  are  found.  These  are  claimed  to  be 
mucus  corpuscles.  Some  observers  affirm  that  while  they  react  to 
acetic  acid  the  same  as  pus  cells,  still  if  they  exhibit  only  one  or  two 
nuclei  they  are  mucus  corpuscles.  Their  true  character  has  an 
important  financial  bearing  to  persons  under  examination  for  life 
insurance. 


222  PHYSICAL  DIAGNOSIS. 

or  their  edges  become  crenated  and  the  protoplasm 
granular  (Fig.  25).  They  are  rapidly  destroyed  by  am- 
moniacal  changes  in  the  urine.  Their  presence  indicates 
haemorrhage  into  the  genito-urinary  tract.     The  diseases 

of  the  kidney  in  which  they 
most  frequently  occur  are  con- 
gestion, acute  nephritis,  cal- 
culus, cancer,  and  embolism. 
They  may  be  found  also  in 
certain  blood  states,  as  pur- 
pura, scurvy,  etc.  In  women 
the  menstrual  discharge  may 
contaminate  the  urine.  The 
other  organic  constituents 
^^  (epithelium,  casts,  etc.)  which 
may  be  associated  with  the 
blood  corpuscles  aid  in  deter- 
fig.  53.-B,  superficial  layers  of  biad-  mining  their  origin. 

der;  B2,  deeper  layers  of  bladder;  V,          -17,  m-  M\ 

cells  from  vagina;  U,  ciliated  cells  from          -H-PITHELIUM  (^  lg.        06). — 

cervix  ut,ri;C,  from  uterine  mucosa;  Three    principal  varieties     of 
P,  from  pelvis  of  kidney;  T,  from  tu-                        r             * 

buies  of  kidney;  g,  from  prostatic  por-  epithelial  cells  are  f ound  in 

tion  of  urethra. 

the  urine :  squamous  cells, 
from  the  bladder,  vagina,  or  orifice  of  the  urethra  ;  co- 
lumnar cells,  from  the  deeper  layers  of  the  pelvis  of  the 
kidney,  or  from  the  uterus — they  may  be  ciliated  when 
from  the  uterus  ;  and  spherical  cells,  which  have  their 
origin  in  the  tubules  of  the  kidney,  or  from  the  deeper 
layers  of  the  mucous  membrane  of  the  pelvis  of  the  kid- 
ney, of  the  ureter,  bladder,  or  urethra.  Eenal  epithe- 
lium has  a  polygonal,  well-defined  outline,  is  slightly 
larger  than  a  pus  cell,  and  has  a  large  oval  nucleus.  The 
presence  of  such  cells  in  a  cast  at  once  determines  their 
origin.  Tailed  cells  from  the  superficial  layer  of  the 
pelvis  of  the  kidney  are  sometimes  found. 


URINE. 


223 


Spermatozoa.—  When  found  in  urine,  these  bodies 
have  the  characteristic  tadpole  appearance  (Fig.  54),  but 
thev  no  longer  possess  any  power  of 
motion.1  They  are  present  imme- 
diately after  all  seminal  emissions  : 
often  after  defecation,  especially  if 
constipation  is  extreme  ;  and  after 
epileptic  seizures.  They  have  been 
found  in  the  urine  of  women  after 
coitus.  They  are  occasionally  found 
in  typhus  and  typhoid  fevers. 

Casts. — These  are  moulds  of  the  tubules  of  the  kid- 
ney, formed  by  the  effusion  of  materials  that  coagu- 
late spontaneously.  They  often  enclose  formed  ele- 
ments. Their  diameter  varies  from  Tl  ¥  to  y-Vo  inch,  or 
even  smaller. 

Hyaline. — Hyaline  casts  are  transparent,  structure- 
less cylinders,  often  invisible  with  strong  illumination. 
Their    extremities    are   generally    rounded  or    slightly 


Spermatozoa. 


F13.  5o.— Types  of  Hyaline  Casts. 


clubbed,  but,  from  a  tendency  to  fracture  transversely, 
fragments  are  often  found  with  straight  ends  (Fig.  55). 

1  In  medicolegal  cas  s  (rape)  the  vaginal  discharge  should  be 
examined  for  spermatozoa.  Pieces  of  clothing  supposed  to  be 
stained  with  seminal  fluid  are  macerated  with  distilled  water  in  a 
test  tube,  for  a  short  time;  after  shaking  thoroughly,  the  pieces  are 
removed,  the  sediment  allowed  to  settle  and  examined. 


224 


PHYSICAL   DIAGNOSIS. 


Small  hyaline  casts  are  found  in  the  acute  (inflamma- 
tory) stage  of  nephritis,  when  they  are  generally  asso- 
ciated with  other  varieties,  and  the  urine  is  markedly 
albuminous.  Large  hyaline  casts  are  found  in  the  atro- 
phic stages  of  all  forms  of  Bright's  disease.  Hyaline 
casts  may  have  pus  cells  or  renal  epithelium  adhering  to 
their  surface.  At  times  a  few  hyaline  casts  are  found  in 
urine  that  is  non-albuminous  and  contains  no  other 
evidence  of  kidney  disease.  In  such  cases  they  have  no 
diagnostic  value. 

Waxy    casts    are    a   variety    of  hyaline.     Generally 
they  are  of  yellowish  color.     At  times  they  give  the 


Fig.  56.— Epithelial  Casts.  Fig.  57.— Granular  Casts. 

amyloid  reaction  with  iodine  and  iodide  of  potash,  but 
this  is  not  pathognomonic. 

Epithelial. — These  show  the  characteristic  epithelium 
of  the  tubules  of  the  kidney.  The  cells  may  have 
a  normal  appearance,  or  are  more  or  less  broken  down 
and  degenerated.  The  casts  may  be  composed  entirely 
of  renal  epithelium,  or  a  few  cells  only  may  be  en- 
trapped in  a  hyaline  cast  (Fig.  56). 

Epithelial  casts  are  present  in  desquamative  nephritis. 
When  pus  cells  are  mingled  with  renal  epithelium  in 
casts,  the  inflammatory  changes  in  kidney  are  exten- 
sive. 

Granular. — Granular  casts  vary  greatly  in  size,  color, 
and  appearance.  Their  outline  is  well  marked,  and  one 
or  both  ends  generally  rounded  (Fig.  57).     The  granular 


URINE. 


225 


matter  may  be  composed  0*  the  debris  of  epithelium, 
pus,  or  blood.  In  the  early  stages  of  nephritis  they  are 
associated  with  epithelial  casts.  When  granular  casts 
only  are  present,  they  indicate  the  large,  white  kidney, 
or  that  extensive  destruction  of  the  parenchyma  of  the 
kidney  is  taking  place. 

Fatty. — The  oil  globules  may  be  in  degenerated  epithe- 
lium (a  variety  of  granular  casts),  or  may  themselves  con- 
stitute the  cast  (Fig.  58).  This  variety  is  indicative  of 
the  large  white  kidney,  or  the  contracted  kidney  with 
marked  fatty  degeneration. 

Blood   (Fig.  59)- — The  presence  of  a  few  red  blood  cor- 


Fig.  58.— Fatty  Casts. 


Fig.  59.— Blood  Casts. 


puscles  in  an  epithelial  cast  indicates  the  acute  stage  of 
kidney  disease.  When  they  constitute  the  entire  cellu- 
lar element  they  are  diagnostic  of  renal  haematuria. 
When  they  appear  without  other  evidences  of  acute  con- 
gestion of  the  kidney,  or  traumatism,  disease  of  the  renal 
blood  vessels,  especially  amyloid  or  fatty  degeneration 
of  the  Malpighian  tuft,  must  be  considered. 

Casts   composed    of  micrococci  are  often   present  in 
septic  embolism  of  the  kidney. 2 

1  The   microscopical  appearance   of  extraneous  matter,    as   hair, 
fibres  of  silk,  linen,  cotton,  etc.,  should   be   so  well   known  as  not 
to  be  mistaken  for  casts . 
17 


226  PHYSICAL  DIAGNOSIS. 

MICKO-ORGANISMS. 

Non-pathogenic. — These  include  those  forms  found 
in  urine  that  has  undergone  fermentation.  When  pre- 
sent in  freshly  voided  urine  they  indicate  that  this  pro- 
cess is  going  on  in  the  urinary  tract. 

The  most  common  forms  are :  Torula  cerevisiee 
(Fig.  60),  found  in  diabetic  urine;  Penicihum  glaucum 
(Fig.  61);  a  small  form  of  Sarcina  (Fig.  62);  and  Micro- 
coccus ureae. 

Pathogenic  Gonococci. — These  are  spheroidal  bod- 
ies, occurring  in  pairs  (diplococci)   or  groups  of  pairs. 


Fig.  60.— Torula  Cerevisiae.         Fig.  61.— Penicilium  Glaucum.         Fig.  62.— Sarcinse. 

X  300.  X  300. 

Between  the  associated  cocci  there  is  a  slight  space. 
Their  opposing  sides  are  somewhat  flattened,  giving  the 
characteristic  coffee-bean  appearance.  They  must  be 
stained  to  be  demonstrated. 

A  drop  of  pus  from  the  urine,  or  direct  from  the  meatus 
urinarius,  is  smeared  upon  a  cover  glass,  which,  after  it 
has  dried,  is  passed  slowly  through  a  flame  to  fix  the  film. 
A  few  drops  of  a  solution  of  methyl  blue  (see  Sputum)  are 
placed  on  the  specimen  for  a  few  minutes,  the  excess  of 
dye  is  washed  off,  and  the  specimen  examined  with  an 
oil-immersion  lens  or  a  No.  1  objective.  Gonococci, 
stained  blue,  appear  free  on  the  epithelium  and  in  the 


URINE.  227 

pus  cells  (Fig.  63).  The  diagnostic  feature  is  the  presence 
of  the  gonococci  in  the  pus  cells.  In  the  urethra  non- 
pathogenic diplococci  are  sometimes  found.  They  are 
slightly  larger  than  gonococci,  aod  may  exist  free  or  in 
the  epithelial  cells,  but  are  not  found  in  the  pus  cells. 

G-onococci  in  pus,  whether  urethral,  vaginal,  or  con- 
junctival, are  diagnostic  of  gonorrhoeal  infection. 

Tubercle  Bacilli  are  indicative  of  tubercular  ulcera- 
tion somewhere  along  the  genito -urinary  tract.  (For 
method  of  staining,  etc:,  see  Sputum.) 


Fig.  63.— Gonococci.    (After  Sternberg.) 

Actinomyces  may  appear  in  the  urine  when  the 
genito-urinary  tract  is  primarily  or  secondarily  involved. 

PARASITES. 

Filaria  Sanguinis  Hominis  (Fig.  32,  page  206). — These 
bodies  often  appear  in  the  chylous  urine  of  patients 
whose  blood  is  infected.  In  addition  to  the  oil  globules, 
pus  and  blood  may  be  found  in  the  urine. 

Echinococci,  hooklets,  and  portions  of  cysts  may  ap- 
pear in  the  urine  when  a  hydatid  cyst  has  formed  in 
the  genito-urinary  tract  or  ruptured  into  it  from  neigh- 
boring organs  (Fig.  39,  page  215). 


228  PHYSICAL   DIAGNOSIS. 

Vomit. 

The  vomit  may  contain  elements  from  the  oesophagus 
and  respiratory  tract  besides  the  contents  of  the  stom- 
ach. The  microscopical  examination  may  show  the 
presence  of  food  masses,  such  as  muscle  fibres,  with 
well-marked  striations,  oil  globules,  needle-shaped  fat 
crystals,  connective-tissue  fibres,  starch  granules  more 
or  less  altered,  and  vegetable  cells.  These,  of  them- 
selves, are  of  no  diagnostic  value,  but  may  give  a  hint 
as  to  the  rapidity  of  the  digestive  process. 

Bed  Blood  Corpuscles,  showing  their  characteristic 
appearance,  may  be  found  in  the  vomit  where  haemor- 
rhage into  the  stomach  has  been 
so  great  and  its  expulsion  so 
rapid  as  not  to  allow  the  gastric 
juice  to  act  upon  them,  or  when 
blood  is  added  to  the  vomited 
matter  above  the  stomach. 
When  acted  on  by  gastric  juice 
the  corpuscles  are  destroyed, 
and  their  contents  appear  as 
fig.  64.-Haemin  crystals.  masses    of    reddish-brown    pig- 

ment (coffee-grounds).  To  determine  the  presence  of 
blood  in  such  cases,  some  of  the  suspected  matter  is 
dried,  ground  into  a  powder,  and  placed  on  a  slide.  A 
few  crystals  of  common  salt  are  added,  and  a  cover  glass 
put  on.  A  little  glacial  acetic  acid  is  allowed  to  flow 
under  the  cover  glass,  and  the  slide  is  heated  (not  to 
boiling)  for  a  few  minutes.  The  salt  is  dissolved  out  in 
a  little  water.  If  the  specimen  contains  blood,  small, 
dark,  rhombic  crystals  of  haemin  will  be  seen  (Fig.  64). 

Pus  Cells  are  also  destroyed  by  gastric  juice.  They 
only  appear  in  the  vomit  when  there  is  a  suppurative 


F.ECES.  229 

inflammation  of  the  stomach  walls,  or  when  a  large 
abscess  has  ruptured  into  the  stomach. 

The  Epithelial  Cells  found  in  the  vomit  are  of  the 
squamous  or  columnar  type.  Squamous  cells  come  from 
the  oesophagus  or  mouth  ;  columnar  cells  from  the  gas- 
tric mucous  membrane. 

Sarcestje  vextriculi,  having  the  characteristic  "  wool 
pack  "  appearance  (Fig.  62,  page  226),  are  often  found. 
They  are  present  when  the  stomach  retains  its  contents 
for  a  long  time,  especially  in  dilatation  of  the  organ. 

Tubercle  Bacilli,,  when  found  in  the  vomit,  indicate 
a  tubercular  ulceration  in  the  food  passages  or  contami- 
nation of  the  vomit  by  sputum. 

Fceces. 

The  number  and  character  of  food  residues  found  in 
the  f  aeces  depend  upon  the  diet.  In  a  general  mixed  diet 
there  will  be  found  vegetable  cells,  starch  granules,  mus- 
cle fibres,  elastic  and  white  fibrous  tissue,  and  fat  glo- 
bules ;  while  in  the  stools  of  children  and  adults  fed 
exclusively  upon  milk  large  quantities  of  fat  and  crys- 
tals of  fatty  acids  will  be  found. 

Eed  Blood  Corpuscles  do  not  present  their  charac- 
teristic form  unless  a  large  quantity  of  blood  has  been 
thrown  into  the  intestines  and  rapidly  voided,  or  its  ori- 
gin is  in  the  lower  portion  of  the  large  intestine,  as  from 
hseniorrhoids  (in  women  contamination  with  the  men- 
strual flow  must  be  considered).  When  blood  has  been 
retained  for  some  time,  no  corpuscles  can  be  detected,  but 
it  is  changed  to  a  "tarry"  or  dark -brown  mass  (see 
Vomit). 

Pus  Cells  are  rarely  present  in  healthy  stools.  In 
simple  intestinal  catarrh  only  a  few  are  present.  When 
found  in  large  numbers  they  are  due  to  ulceration  of 


230  PHYSICAL  DIAGNOSIS. 

some  portion  of  the  intestinal  tract.  Pure  purulent  dis- 
charges take  place  only  when  an  abscess  has  ruptured 
into  the  intestines,  and  occasionally  in  dysentery. 

Epithelium,  in  small  amount  and  more  or  less  altered, 
is  always  found  in  healthy  faeces  and  has  no  diagnostic 
significance.  When  found  in  large  quantity  it  is  indica- 
tive of  intestinal  catarrh. 

MICRO-ORGANISMS. 

Large  numbers  of  micro-organisms  are  found  in  the 
fasces  ;  most  of  them  are  non-pathogenic.     Some  which 


Fig.  65.— Cholera  Bacilli  from  Fasces.  X  900.  (Drawn  by  J.  M.  Byron,  M.D. ,  Loomis 
Laboratory.) 

are  found  in  unhealthy  stools  are  also  present  in  the 
healthy — they  seem  to  be  concomitants,  and  not  exci- 
tants, of  the  diseased  condition.  They  have  no  diag- 
nostic value. 

The  pathogenic  bacteria  are  the — 

Cholera  Bacillus  {Comma  Bacillus). — This  appears 
as  a  short,  curved  rod  that  is  thicker  than  the  tubercle 
bacillus  (Fig.  65).  Two  bacilli  may  be  so  placed  as  to 
give  the  peculiar   S-like   appearance.     They  are  found 


FAECES.  231 

most  abundantly  in  the  free  mucous  flocculi  of  the  rice- 
water  discharges.  A  cover-glass  preparation  may  be 
made  and  stained  with  methyl  blue,  as  for  gonococci. 

Bacillus  of  Typhoid  Fever  {Bacillus  of  Eberth). — 
This  appears  as  a  rod  with  rounded  extremities  ;  its 
length  is  about  one-third  the  diameter  of  red  blood  cor- 
puscles, and  its  width  one-third  its  length  (Fig.  30,  page 
205).  Spores  are  sometimes  seen  in  the  rods.  They 
stain  with  a  watery  solution  of  methyl  blue. 

The  bacilli  of  cholera  and  typhoid  fever,  as  they  ap- 
pear in  the  faeces,  cannot  be  differentiated  by  their 
appearance,  or  by  their  reaction  with  the  staining  solu- 
tions, from  other  bacteria  having  similar  form.  To  de- 
cide their  true  nature  it  is  necessary  to  make  cultures. 

Tubercle  Bacilli  may  be  found  in  the  stool  when 
there  is  tubercular  ulceration  of  the  intestine,  or  when 
tubercular  sputum  has  been  swallowed. 

ANIMAL   PARASITES. 

AmcebvE  Coll — These  are  cellular  bodies,  three  to  four 
times  as  large  as  a  pus  cell,  having  a  distinct  nucleus. 
Their  protoplasm  is  hyaline  or  coarsely  granular  and 
may  contain  vacuoles.  When  seen  im- 
mediately after  voiding,  they  often  show 
amoeboid  movements  (Fig.  66).  They 
have  important  diagnostic  significance 
in  relation  to  dysentery  and  abscess  of 
the  liver. 

Fig.  66.  —  Amce- 

The    ova    of    onlv    certain   intestinal        b8e  Coli-    cAfter 

VonJakseh.) 

worms  will  be  considered. 

Distoma  Hepaticum. — The  eggs  are  oval,  0.13  mm. 
long  by  0.08  mm.  broad.  One  extremity  is  broader  than 
the  other  and  opens  with  lid  ;  the  shell  is  brown  and  is 
composed  of  two  layers. 


232 


PHYSICAL   DIAGNOSIS. 


T^nia  Solium.— The  eggs  are  nearly  spherical,  0.036 
mm.  long  by  0.03  mm.  wide.  The  outer  covering  or 
shell  has  radiating  lines.  When  fully  formed,  hooklets 
can  be  demonstrated  on  the  embryo. 

T^nia  Mediocanellata.— The  eggs  are  slightly  more 
oblong  than  those  of  the  solium,  and  exhibit  a  primor- 
dial yolk  membrane.  The  embryo  does  not  show  hook- 
lets. 

Bothriocephalus  Latus. — The  eggs  are  oval,  0.07 
mm.  long  by  0.045  mm.  broad  ;  the  shell  is  brown,  and 


Fig.  67.— Eggs  of  Intestinal  Ova.  1,  Egg  of  Distoma  hepaticum;  2,  Distoma  lanceo- 
latum ;  3,  Taenia  solium ;  4,  Taenia  mediocanellata;  6.  Bothriocephalus  latus ;  6, 
Oxyuris  vermicularis ;  7,  Trichocepbalus  dispar;  8,  Ascaris  lumbricoides.  (After 
Strumpell.) 

one  end  is  small,  opening  with  a  lid.  The  protoplasm  of 
the  egg  is  divided  into  small  masses  of  uniform  size. 

Trichocephalus  Dispar. — The  eggs  are  characterized 
by  a  well-marked  swelling  at  each  end  of  the  shell. 

Ascaris  Lumbricoides. — The  eggs  are  nearly  spherical, 
0.06  by  0.07  mm.  ;  the  shell  is  of  a  brownish-yellow 
color,  and  encloses  granular  contents. 

Anchylostoma  Duodenale. — The  eggs  are  oval,  0.05 
by  0.06  mm.,  and  are  enclosed  within  a  shell.  They 
often  contain  daughter-cells. 


MECHANICAL    AIDS   TO 
DIAGNOSIS. 


18 


LESSOR  XIX. 


MECHANICAL    AIDS    IN    THE    DIAGNOSIS     OF    THE     DISEASES 

OF   THE  RESPIRATORY  AND  VASCULAR  ORGANS — 

STETHOSCOPE — STETHOMETER — CYRTOMETER — 

CARDIOMETER — LARYNGOSCOPE — 

SPHYGMOGRAPH. 

I  will  now  briefly  describe  the  different  instruments 
which  may  be  employed  as  aids  in  physical  diagnosis, 
and  give  some  rules  to  guide  you  in 
their  use. 

Stethoscope. 

In  the  diagnosis  of  diseases  of  the 
respiratory  and  vascular  organs,  a 
stethoscope  is  not  only  often  con- 
venient, but  at  times  absolutely  es- 
sential. A  great  variety  of  stetho- 
scopes have  been  devised,  each  in- 
ventor claiming  for  his  own  instru- 
ment some  superiority  in  principle 
or  shape.  They  may  all  be  referred 
to  two  general  classes,  viz.,  flexible 
and  solid.  For  general  use  I  would 
recommend  the  binaural  stethoscope 
devised  by  the  late  Dr.  Cammann, 
of  this  city.  It  has  two  flexible 
tubes  fitted  into  the  cup  that  is  ap- 
plied to  the  surface.     These  are  con- 

Fiq.  68.— Stethoscope. 

tinuous    with   two   metal  tubes    so 

curved  that  they  fit  into  each  ear,  and  are  connected 


236 


PHYSICAL  DIAGNOSIS. 


with  each  other  by  means  of  a  metal  bar  with  a  toggle 
joint  in  its  centre.  An  elastic  band  holds  them  in 
position  (see  Fig.  68). 

It  requires  some  practice  to  become  adepts  in  its  use. 
But,  once  accustomed  to  it,  you  will  find  it  has  no  supe- 
rior.    It  closes  both  ears  to  all  but  the  desired  sounds. 

In  selecting  a  stethoscope  you  should  be  careful  that 
the  ear  pieces  exactly  fit  your  ears.  If  they  are  too 
large,  they  will  cause  pain  ;  and  if  too  small,  they  will 
produce  a  roaring  noise  which  will  obscure  the  sounds 
you  desire  to  examine. 

In  cardiac  auscultation,  and  in  determining  abnormal- 
ities of  the  blood  vessels,  this  instrument  will  be  found 
almost  indispensable ;  for  pulmonary  auscultation  it  is 
only  occasionally  of  service. 


Stethometer. 

The  simplest  way  to  ascertain  the  circular  measure- 
ment or  amount  of  motion  of  the  chest  or  abdomen  is 
by  means  of  an  ordinary  pocket  tape. 
But  Dr.  Quain  has  devised  an  in- 
strument for  this  purpose,  called  the 
stethometer. 

It  consists  of  a  brass  box  with  a 
dial,  and  an  index  which  is  moved 
by  a  rack  attached  to  a  silken  cord. 
One  revolution  of  the  index  indicates 
an  inch  of  motion,  the  intervening 
space  being  graduated,  as  shown  in 
Fig.  69. 

It  may  be  employed  when  the  patient  is  in  a  standing, 
sitting,  or  recumbent  posture.  The  mode  of  its  applica- 
tion is  as  follows :  Place  the  box  on  the  sternum  with 
the  index  pointing  to  the  median  line  ;  carry  the  silken 


Fig.  69.— Stethometer. 


CYRTOMETER. 


237 


cord  around  the  chest  to  the  spines  of  the  vertebrae, 
where  it  should  be  held  firmly  with  the  thumb  or  finger. 

The  amount  of  motion  of  the  side  under  examination, 
from  the  end  of  an  expiration  to  the  end  of  a  full  inspi- 
ration, will  be  accurately  shown  by  the  index. 

This  instrument  is  of  great  utility  in  determining  the 
exact  amount  of  difference  in  the  expansion  of  the  two 
sides  of  the  chest,  as  well  as  for  determining  the  amount 
of  local  expansion  in  any  region. 


Fig.  70.—  Cyrtometer. 


Cyrtometer. 

It  frequently  happens  that  the  exact  shape  of  the 
chest  or  abdomen  is  far  more  important  than  the  amount 
of  motion.  An  instrument  to  determine  this  was  made 
in  1860  by  G.  Tiemann  &  Co.  from  suggestions  given 
them  by  Prof.  Austin  Flint.  It  resembles  in  principle 
the  cyrtometer  of  Woiller,  invented  in  1857. ' 
1  Vide  Gazette  des  H6pitaux,  1857,  p.  134. 


230  PHYSICAL   DIAGNOSIS. 

It  consists  of  an  ordinary  compass  with  short  arms ; 
slits  are  made  in  the  ends  of  these  arms  to  receive  nar- 
row strips  of  lead,  which  are  made  long  enough  to  en- 
circle the  chest  and  meet  in  the  median  line  in  front ; 
they  are  fastened  into  the  arms  of  the  compass  by 
means  of  thumb  screws.  An  indicator  is  attached  to 
the  centre  of  one  arm,  and  slides  through  the  other ; 
this  is  arrested  at  any  point  by  means  of  a  thumb  screw 
(Fig.  70). 

When  applied,  the  arms  of  the  compass  are  pressed 
on  each  side  of  the  vertebral  column  and  fastened  by 
means  of  the  thumb  screw  pressing  on  the  indicator  ; 
the  strips  of  lead  are  moulded  so  as  to  fit  any  depression 
or  elevation  of  the  chest  ;  the  thumb  screw  is  then  loos- 
ened and  the  instrument  removed.  After  its  removal, 
bring  the  arms  of  the  compass  together  until  they  reach 
the  same  notch  in  the  indicator  as  when  the  instrument 
was  applied  to  the  chest ;  fasten  it  with  the  thumb 
screw,  place  it  upon  paper,  and  you  can  easily  trace  the 
exact  shape  of  the  chest. 

Cardiometer. 

The  cardiometer  was  devised  by  the  late  Dr.  Cam- 
mann  to  determine  accurately  the  distance  of  the  apex 
beat  from  the  median  line.  It  resembles  a  pocket  knife 
in  shape,  with  one  extremity  rounded  and  the  other 
slightly  pointed.  On  its  handle  is  a  scale  of  inches 
which  may  be  used  as  an  ordinary  rule.  Enclosed  in 
the  handle  is  a  graduated  blade,  which  runs  its  whole 
length  and  is  attached  by  a  pivot  to  the  rounded  ex- 
tremity. This  blade  is  pointed  at  its  free  extremity 
and  has  a  slit  through  its  centre.  A  small  arm  is  con- 
nected to  one  side  of  the  handle,  by  means  of  a  pivot, 
near  its  rounded  extremity  ;  the  free  end  slides  along 


LARYNGOSCOPE. 


239 


the  slit  in  the  blade  and  has  a  small  indicator  attached 
to  it.  As  the  instrument  is  opened  the  indicator  marks 
the  number  of  inches  between  the  extremity  of  the 
blade  and  the  extremity  of  the  handle  (see  Fig.  71). 

In  using  this  instrument,  place  the  pointed  extremity 
of  the  handle  on  the  median  line  and  open  the  blade  to 


Fig.  71.— Cardiometer. 

a  point  corresponding  to  the  apex  beat.  By  reading  the 
scale,  the  distance  of  the  apex  beat  from  the  median 
line  is  determined. 

In  recording  cases,  and  in  accurately  determining- 
slight  changes  in  the  position  of  the  apex  beat,  this 
instrument  will  be  found  of  service. 

Laryngoscope. 

The  apparatus  consists  of  three  parts — the  throat 
mirror,  the  head  or  reflecting  mirror,  and  the  source  of 


G.  TIEMANN  =  CO 


Fig.  72.— Laryngeal  Mirror. 


illumination.     It  is  used  to  examine  the  nose  and  upper 
air  passages. 

The   throat  or   laryngeal  mirror  is   a    small   mirror 


240 


PHYSICAL   DIAGNOSIS. 


mounted  in  a  German- silver  frame  and  attached  to  a 
delicate  handle  from  six  to  seven  inches  long.  It  is 
made  in  six  sizes,  varying  from  three-eighths  of  an  inch 
to  one  inch  in  diameter.  There  are  several  different 
shapes,  but  the  round  mirror  is  best  adapted  to  general 
purposes.  For  laryngoscopic  work  the  mirror  is  attached 
to  the  handle  at  an  angle  of  135°  ;  for  rhinoscopic,  at  an 
angle  of  105°. 

The  reflecting  mirror  is  a  large  concave  mirror,  perfo- 
rated in  its  centre  so  that  the 
illuminating  and  visual  rays 
will  be  in  the  same  axis.  It 
should  not  be  too  large,  or  its 
weight  will  become  objection- 
able. The  mirror  is  attached 
to  a  head  band  by  means  of  a 
ball-and-socket  joint,  to  give 
perfect  freedom  of  motion. 

Source  of  Illumination.  — 
Sunlight  is  to  be  preferred 
because  of  its  whiteness,  but 
the  Argand  burner  or  a  coal- 
oil  lamp  may  be  used.  Sajous 
states  that  a  small  piece  of 
camphor  dissolved  in  the  oil 
will  make  the  light  whiter.  A  condenser  may  be  used 
to  increase  the  intensity  of  the  light. 

Method  of  Examining  the  Larynx. — So  adjust  the 
reflecting  mirror  that  the  opening  in  its  centre  corre- 
sponds to  the  line  of  vision,  and  that  the  light  is  thrown 
into  the  patient's  mouth.  Then  direct  the  patient  to 
catch  the  tip  of  his  tongue  in  a  napkin  and  draw  it  well 
forward.  Take  the  throat  mirror,  previously  warmed 
over  the  lamp  (to  prevent  the  condensation  of  moisture 


Fi£  73.— Head  Mirror. 


LARYNGOSCOPE.  241 

on  its  surface),  lightly  in  the  right  hand,  and  introduce  it 
into  the  back  of  the  throat  with  its  face  directed  down- 
ward. It  should  not  touch  the  base  of  the  tongue,  or 
retching  may  be  excited.  Let  the  posterior  surface  of 
the  mirror  rest  against  the  base  of  the  uvula,  and  push 
it  upward  and  backward  toward  the  vault  of  the  pha- 
rynx. The  plane  of  the  mirror  should  form  an  angle 
of  about  45°  with  the  horizon. 

If  the  throat  is  irritable,  the  mirror  should  be  removed 
and  the  patient  allowed  to  rest  a  few  minutes  before 
another  attempt  at  examination  is  made.  It  may  be 
necessary  to  produce  local  anaesthesia  by  means  of  a  ten- 
per-cent  solution  of  cocaine  ;  but  this  procedure  is  to  be 
avoided,  as  a  sense  of  choking  is  thereby  produced.  The 
administration  of  a  small  dose  of  potassium  bromide  a 
few  hours  previous  to  the  examination  will  be  found  of 
service  in  rendering  the  parts  less  irritable. 

Laryngoscopical  View  of  the  Larynx  in  a  Nor- 
mal Condition. — In  the  laryngeal  mirror,  when  it  has 
been  introduced  into  the  pharynx  as  already  directed, 
the  first  thing  that  comes  into  view  is  the  back  of  the 
tongue  with  its  large  follicles,  then  the  hollow  space  be- 
tween it  and  the  anterior  or  glossal  surface  of  the  epi- 
glottis, which  is  of  a  dark- pink  color. 

Next,  the  apex  and  laryngeal  surface  of  the  epiglottis, 
the  free  surface  being  of  a  yellow  color,  while  the  laryn- 
geal or  under  surface  is  invariably  of  a  bright-red  color. 

Next,  the  ary -epiglottic  folds,  which  are  of  about  the 
same  color  as  the  mucous  membranes  of  the  gums. 

Next,  the  ventricular  bands,  having  about  the  same 
color  as  the  mucous  lining  of  the  lips. 

Next,  the  vocal  cords,  which  are  pearly  white,  like  the 
sclerotic  coat  of  the  eye. 

Next,   the    tracheal  rings,  which  are   of  a  decidedly 


242  PHYSICAL    DIAGNOSIS. 

yellow  color,  the  mucous  membrane  between  them  being 
of  a  bright  red. 

Lastly,  the  bifurcation  of  the  trachea  and  the  bronchi. 

In  making  your  laryngeal  observations,  as  soon  as  the 
posterior  wall  of  the  larynx  is  brought  into  view,  note 
carefully  the  form,  size,  color,  position,  and  mobility  of 
the  true  and  false  vocal  cords,  as  well  as  all  their  rela- 
tions and  form  of  motion,  also  the  appearance  of  the 
anterior  wall  of  the  larynx  from  the  free  border  of  the 
epiglottis  down  to  the  trachea. 

For  the  purpose  of  investigating  the  action  of  the 
vocal  cords,  the  patient  should  be  directed  to  inspire 
deeply  or  to  produce  a  vocal  sound,  as  ah  or  eh. 

You  must  remember  that  the  objects  seen  in  the  laryn- 
geal mirror  are  reversed  :  the  anterior  part  of  the  larynx 
becomes  the  posterior  ;  but  the  right  side  remains  the 
right,  and  the  left  remains  the  left.  This  reversed  pic- 
ture is  somewhat  troublesome  to  the  beginner.  By  fre- 
quently examining  the  different  parts  in  the  order  al- 
ready given,  you  will  become  familiar  with  their  normal 
appearance  and  motions,  and  be  prepared  to  recognize 
abnormalities. 

The  laryngeal  diseases  in  which  the  laryngoscope  is 
of  special  service  as  an  aid  in  diagnosis,  are  thickening, 
induration,  and  ulcerations  of  the  vocal  cords,  paralysis 
of  the  vocal  cords,  polypi  or  malignant  growths  spring- 
ing from  any  portion  of  the  larynx,  exudation  on  the 
mucous  surface  of  the  epiglottis  or  larynx,  follicular  en- 
largements, and  ulcerations  of  the  larynx,  as  well  as 
other  changes  which  may  occur  in  the  course  of  chronic 
laryngitis  or  tracheitis. 

Rhinoscopy. 
The  examination  may  be  made  through  the  anterior 


RHINOSCOPY. 


243 


or  posterior  nares,  and  is  called,  accordingly,  anterior 
or  posterior  rhinoscopy.  The  anterior  examination  is 
by  far  the  more  satisfactory. 

Anterior  Rhinoscopy.— Dilate  the  nostril  by  means  of 
a  nasal  speculum  (Fig.  74),  and  throw  the  light  from  the 
reflecting  mirror  into  the  cavity.  By  placing  the  fingers 
of  the  left  hand  on  the  forehead  of 
the  patient,  and  pressing  the  tip 
of  the  nose  upward  with  the 
thumb,  the  opening  is  much  en- 
larged. The  head  of  the  patient 
should  be  on  a  level  with  that  of 
the  examiner.  Inspect  the  infe- 
rior meatus  first.  Then,  by  turn- 
ing the  head  of  the  patient  slightly 
from  side  to  side,  the  surface  of 
the  septum  and  that  of  the  inferior 
turbinated  body  will  be  brought 
successively  into  view.  Now  tilt 
the  head  backward  until  the  mid- 
dle turbinated  body  is  seen,  and 
examine  its  surface  and  that  of 
the  septum  opposite.  By  further 
tilting,  the  anterior  end  of  this 
body  and  the  vestibule  of  the  nose 
can  be  seen. 

A  ten-  or  twenty-per-cent  solution  of  cocaine  is  now 
thrown  into  the  cavity,,  and,  after  allowing  sufficient  time 
for  the  contraction  of  the  blood  vessels,  the  same  pro- 
cedure is  repeated. 

Posterior  Rhinoscopy. — Pass  the  tongue  depressor 
well  over  the  arch  of  the  tongue  and  pull  its  base  for- 
ward, depressing  it  at  the  same  time.  You  must  be  care- 
ful not  to  crowd  it  back  into  the  throat,  or  retching  may 


Fig.  74.— Nasal  Speculum. 


244  PHYSICAL   DIAGNOSIS. 

thereby  be  excited.  Warm  the  rhinoscopic  mirror  and 
introduce  it  sidewise  between  the  uvula  and  left-  pillar 
of  the  fauces-  When  it  is  well  in  the  pharynx,  with  its 
face  directed  forward  and  slightly  upward,  turn  it  gently 
until  the  posterior  nares  are  brought  into  view. 

The  septum  is  seen  in  the  median  line  separating  the 
oval  openings  of  the  nares.  On  each  side  of  the  sep- 
tum the  nasal  passages  appear  as  dark  cavities.  The 
superior  turbinated  body  is  visible  in  the  upper  part  of 
each  cavity  as  a  faint  reddish  band  ;  below  it  is  the 
middle  turbinated  body,  appearing  as  an  elongated  mass 
of  a  yellowish-red  color  ;  while  between  the  two  posteri- 
orly is  a  dark  line — the  superior  meatus.  Passing  further 
downward  you  come  to  the  middle  meatus  and  the  in- 
ferior turbinated  body,  only  the  upper  half  of  which  can 
be  seen.  It  appears  to  rest  on  the  floor  of  the  nose. 
The  inferior  meatus  cannot  be  brought  into  view. 

By  turning  the  mirror  to  the  side,  the  opening  of  the 
Eustachian  tube  may  be  seen  as  a  dark  slit.  If  the 
handle  of  the  mirror  be  raised,  the  vault  of  the  pharynx 
is  brought  into  view.  It  presents  an  irregular  surface, 
indicating  the  site  of  the  pharyngeal  tonsil. 

These  various  parts  making  up  the  complete  image 
can  be  seen  only  in  detail. 

This  examination  discloses  the  condition  of  the  nasal 
mucous  membrane,  and  such  morbid  alterations  as  may 
exist  there,  as  necrosis,  ulceration,  polypi,  etc.  In  the 
vault  of  the  pharynx  one  can  see  the  condition  of  the 
pharyngeal  tonsil,  and  such  hypertrophy  as  may  be 
present. 

Sphygmograph. 

Various  modifications  of  the  sphygmograph  have  been 
devised  by  different  experimenters,  but  the  one  which 
seems  to  me  to  be  the  best  is  that  which  was  invented 


SPHYGMOGRAPH. 


245 


by  M.  Marey,  of  Paris,  to  determine  various  points  in 
the  physiology  of  the  circulation  of  the  blood. 

This  instrument  consists  of  a  brass  frame  with  a  wing 
fastened  to  each  side  by  hinges,  so  as  to  spread  out  upon 
the  arm  when  the  instrument  is  applied.  Enclosed  in 
this  frame  is  a  flexible  steel  spring,  covered  on  the  under 
surface  of  its  free  extremity  with  an  ivory  button,  which 
rests  upon  the  artery  or  vein  to  be  examined,  and  is  con- 
nected by  means  of  a  bar  of  metal,  which  has  a  vertical 
plate  attached  to  it,  with  a  very  light  lever  moving  upon 
a  pivot ;.  the  vertical  plate  is  brought  in  contact  with  the 
lever  by  means  of  a  screw.  The  free  extremity  of  the 
lever  registers  its  movement  up  a  blackened  strip  of 


Fig.  75.—  Marey 's  Sphygmograph. 

paper  that  covers  the  brass  plate.  This  plate  is  moved 
at  a  uniform  rate  by  means  of  watchwork  placed  in  the 
small  box  beneath.  Ten  seconds  are  occupied  in  the 
passage  of  the  plate.  A  thumb  screw  winds  up  the 
watchwork,  and  a  small  lever  starts  the  plate  or  stops 
it,  as  desired.  Silk  bands  embrace  the  arm  and  hook  on 
to  projecting  points  on  each  wing,  as  seen  in  Fig.  75. 

The  sphygmograph  was  proposed  as  an  aid  in  the 
diagnosis  of  diseases  of  the  heart,  arteries,  and  veins. 
When  properly  adjusted,  it  is  claimed  that  it  gives  an 
exact  representation  of  the  pulse  curve,  the  frequency 
and  regularity  of  the  pulsations,  and  any  peculiarity  of 
the  pulsation.  But  it  has  not  fulfilled  the  expectations 
that  were  entertained  of  it,  for  it  has  been  found  that 


246  PHYSICAL   DIAGNOSIS. 

the  characters  of  a  sphygmogram  may  be  entirely 
changed  by  merely  altering  the  amount  of  pressure  on 
the  arterial  wall.  During  the  excitement,  too,  which 
is  sometimes  brought  on  by  adjusting  the  instrument, 
the  tracing  obtained  is  very  different  from  that  taken 
when  the  heart  is  beating  tranquilly. 

Sphygmograms  are  of  more  importance  in  the  record- 
ing of  cases  and  clinical  teaching  than  in  diagnosis.  By 
means  of  them  we  can  demonstrate  elements  of  the 
pulse  that  would  otherwise  escape  detection. 

Care  must  be  used  in  adjusting  the  instrument,  for  if 
too  much  pressure  is  made  the  arterial  wall  will  be  so 
compressed  as  to  interfere  with  its  free  movement  ;  and 
if  the  pressure  be  too  slight  the  full  movement  of  the 
wall  will  not  be  registered.  In  taking  a  tracing  from 
the  radial  artery,  the  instrument  should  be  applied  to 
the  arm  with  the  ivory  button  resting  on  the  artery  just 
beyond  the  lower  extremity  of  the  radius. 

The  pulse  is  a  wave  of  increased  arterial  pressure, 
started  by  the  systole  of  the  heart,  and  passing  over  the 
arteries  of  the  body.  A  graphic  record  of  this  wave, 
taken  at  any  point  of  an  artery,  is  called  a  pulse  curve. 
It  consists  of  three  parts — the  upstroke  or  anacrotic 
limb,  the  crest,  and  the  down-stroke  or  katacrotic 
limb. 

The  upj-stroke  represents  the  flow  of  blood  into  the 
arteries  and  the  consequent  distention  of  their  walls. 
It  is  nearly  synchronous  with  the  ventricular  systole. 

The  crest  of  the  pulse  curve  designates  the  period  dur- 
ing which  the  artery  reaches  its  greatest  degree  of  dis- 
tention and  begins  to  recoil.  It  is  usually  pointed,  but 
may  be  rounded,  as  in  certain  aneurisms  and  aortic 
stenosis  (see  Figs.  79  and  S3). 

The  down-stroke  represents  the  return  of  the  artery 


SPHYGMOGRAPH.  247 

to  its  original  calibre.  Its  descent  to  the  base  line  is 
gradual.  It  is  broken  by  one  or  more  undulations,  the 
most  prominent  of  which  is  the  dicrotic  crest.  This 
crest  is  sometimes  so  marked  as  to  be  perceptible  to  the 
finger,  giving  rise  to  the  dicrotic  or  "  double  "  pulse. 


Fig.  76.— Normal  tracing.    (After  Bramwell.) 

The  up-stroke  is  from  a  to  b. 

The  crest  is  at  b. 

The  down-stroke  is  from  b  to  a',  with  c  the  predicrotic,  and  d  the  dicrotic  crest. 

In  a  normal  pulse  curve  the  up-stroke  is  nearly  or 
quite  vertical,  the  crest  is  pointed,  and  the  down-stroke 
slopes  gradually  to  the  base  line.  The  predicrotic  and 
dicrotic  crests  are  visible  on  the  down-stroke  (see 
Fig.  76). 


Fig.  77.— A  Dicrotic  Pulse  Tracing.     (After  Eichhorst.) 

Dicrotism  is  favored  by  a  low  arterial  tension,  a  suf- 
ficiently powerful  heart,  elasticity  of  the  vessel  walls, 
and  a  diminished  resistance  in  the  small  arteries.  It 
occurs  in  cases  where  there  is  loss  of  vaso-motor  tone, 
and  in  typhus  and  typhoid  fevers. 

The  prominent  features  of  the  tracing  of  aortic  re- 
gurgitation are  the  suddenness  of  the  down-stroke  and 
the  almost  complete  absence  of  the  dicrotic  crest  (Fig.  78). 


248  PHYSICAL   DIAGNOSIS. 

In  aortic  stenosis  (Fig.  79)  the  blood  is  not  propelled 
into  the  artery  suddenly,  owing  to  the  resistance  it  meets, 


Fig.  78.— Pulse  Tracing  in  Aortic  Regurgitation.    (After  Striiinpell.) 

and  hence  the  up-stroke  is  gradual.     The  crest  in  this 
instance  is  rounded. 

If   atheroma  is  sufficiently  advanced  to  cause   much 
impairment  in  the  elasticity  of  the  arterial  walls,  the 


Fig.  79.— Aortic  Stenosis.    (After  Bramwell.) 

tracing  will  be  as  represented  in  Fig.  80.  Owing  to 
slowness  of  expansion  the  up-stroke  is  gradual.  The 
crest  is  rounded  in  this  case,  though  it  may  sometimes 


Fig.  80.— Tracing  from  a  Case  of  Atheroma.    (After  Eichhorst.) 

be   pointed.     The  loss  in  elasticity  prevents  the  occur- 
rence of  secondary  crests. 

The  frequency  of  the  pulse  may  also  be    studied  by 


SPHYGMOGRAPH. 


249 


means  of  the  sphygmograph.  As  the  plate  moves  at  a 
given  rate  of  speed,  the  number  of  pulse  curves  traced 
duriDg  its  passage  indicates  the  number  of  heart  beats 
in  a  given  number  of  seconds. : 

Fig.  81  is  a  tracing  from  a  case  of  mitral  regurgita- 
tion with  a  rapid  pulse.  It  will  be  seen  that  the  pulse 
curves  follow  each  other  in  quick  succession. 


Fig.  81.— Fmquant  Pulse  (12J  to  130).    (After  Bramwell.) 

The  pulse  may  be  irregular  in  time  or  volume,  or  in 
both.  Irregularities  in  volume  are  usually  associated 
with  irregularity  in  time. 


Fig.  82.— Mitral  Obstruction.    (From  a  patient  in  Bellevue  Hospital.) 
i 

In  Fig.  82,  from  a  case  of  mitral  obstruction,  irregu- 
larity both  in  time  and  volume  is  represented. 


Right  Arm. 


Left  Arm. 
Fig.  83.— Aneurism  of  Ascending  Aorta.    (From  a  patient  in  Bellevue  Hospital.) 

The  passage  of  the  blood  through  an  aneurism  al  sac 
usually  leads  to  a  flattening  of  the  pulse  curves  (see 
Fig.  83)  and  a  retardation  of  the  pulse  on  the  corre- 
sponding side. 

1  Mahomed's  modification  of   Marey's  sphygmograph   is  so  con- 
structed that  foui1  inches  of  the  plate  pass  by  the  point  of  the  pen  in 
ten  seconds. 
19 


LESSOR  XX. 

MECHANICAL  AIDS   IN   THE   DIAGNOSIS  OF  DISEASES  OP   THE 
NERVOUS  SYSTEM,    AND   IN   GENERAL  DISEASES— OPH- 
THALMOSCOPE— THERMOMETER — MICROSCOPE — 
DYNAMOMETER — ^ESTHESIOMETER — EX- 
PLORING    TROCAR — SPECULA. 

Ophthalmoscope. 

The  simplest  and  least  expensive  ophthalmoscope  is 
Liebreich's.1  It  consists  of  a  concave  circular  mirror 
about  one  and  one-half  inches  in  diameter,  and  from  ten 
to  twelve  inches  focal  distance,  perforated  in  the  centre 
by  a  small  circular  aperture.  Behind  the  mirror  is  a 
hinged  clip,  into  which  eye  pieces  may  be  adapted,  three 
of  which  are  concave  and  two  are  convex,  from  six  to 
twelve  inches  focal  distance.  On  the  side  of  the  mirror 
is  a  shank  which  fits  into  a  handle  about  six  inches  in 
length,  by  which  the  mirror  can  be  held  in  any  position 
desired.  In  addition  to  these  there  is  a  convex  object 
lens  of  two  and  one-half  inches  focus  (shown  in  Fig.  84). 

The  examination  is  best  made  in  a  darkened  room,  the 
examiner  and  patient  sitting  or  standing  face  to  face. 

1  The  best  instrument  for  the  direct  method  of  examination  is  that 
of  Dr.  Loring,  of  this  city.  The  refraction  of  the  eye  examined 
may  be  determined  by  its  use,  it  having  a  complete  series  of  convex 
and  concave  glasses,  which,  by  an  ingenious  revolving  disc  ar- 
rangement in  the  mirror,  may  be  placed  before  the  eye  of  the  ob- 
server. The  student  who  desires  to  give  much  attention  to  ophthal- 
moscopy will  probably  prefer  this  instrument,  although  it  is  more 
expensive  than  that  of  Licbreich. 


OPHTHALMOSCOPE.  251 

There  are  two  methods  of  examining  the  eye  with  this 
instrument,  the  direct  and  indirect.  In  both  a  lamp  is 
placed  at  the  side  and  a  little  behind  the  patient's  head, 
the  flame  being  on  a  level  with  his  eyes.  The  handle  of 
the  mirror  is  held  between  the  thumb  and  forefinger, 
and  the  eye  piece  at  the  aperture  of  the  mirror  is 
brought  close  to  one  of  your  own  eyes  in  such  a  manner 
that  the  light  from  the  lamp  is  reflected  into  the  eye 
under  observation.  If  you  desire  to  make  a  direct  ex- 
amination, bring  your  eye  which  is  armed  with  the  mir- 
ror very  close  to  the  patient's  eye,  at  the  same  time  ad- 
justing your  eye  for  objects  at  an  infinite  distance,  that 
is  to  say,  having  the  accommodation  at  rest.     The  ex- 


1 1 EMANN  &CO.  ^SSS 

Fig.  84  — Liebreich's  Ophthalmoscope. 


aminer  should  use  the  corresponding  eye  in  examination 
with  the  one  being  examined.  If  the  eye  of  the  observer 
and  that  of  the  patient  be  of  normal  length,  a  clear 
image  will  be  obtained ;  if  not,  the  proper  correcting 
glass,  convex  or  concave,  may  be  used.  The  patient 
should  turn  his  eye  a  little  outward  and  across  the  room 
upon  some  object. 

In  indirect  examinations  the  lamp  and  mirror  are  ar- 
ranged the  same  as  for  the  direct,  but  the  mirror  is  only 
brought  sufficiently  near  the  eye  to  be  examined  to 
bring  the  focus  of  the  reflection  upon  the  optic  disc  ; 
having  done  this,  take  the  convex  lens  between  the 
thumb  and  first  finger  of  the  hand  not  engaged  with  the 
mirror  ;  rest  the  second  and  third  fingers  of  this  hand 


252  PHYSICAL   DIAGNOSIS. 

on  the  jDatient's  forehead,  so  as  to  steady  the  lens,  and 
move  it  to  and  fro  directly  in  front  of  the  eye  under 
examination  until  you  find  the  focus — your  little  finger 
remains  free  to  raise  the  lid,  if  necessary,  or  to  press 
upon  the  eyeball. 

When  by  practice  you  have  acquired  dexterity  in 
manipulating  this  instrument,  and  by  repeated  examina- 
tions of  the  normal  eye  have  become  f amiliar  with  the 
appearance  of  the  normal  retina,  optic  disc,  and  choroid, 
you  will  be  able  readily  to  recognize  many  of  the  patho- 
logical changes  in  those  structures  which  are  now  be- 
coming important  elements  in  the  diagnosis  of  diseases 
of  the  brain,  spinal  cord,  and  other  vital  organs. 

The  importance  of  this  instrument  in  the  diagnosis  of 
diseases  of  the  eye  is  universally  admitted,  so  that  no 
ophthalmic  surgeon  of  the  present  day  regards  the  ex- 
amination of  an  eye  complete  without  an  ophthalmo- 
scopic examination.  I  shall  not  attempt  to  detail  its 
diagnostic  uses  in  this  branch  of  surgery,  but  will 
briefly  state  its  uses  in  medical  diagnosis,  as  it  is  com- 
ing to  be  regarded  of  no  little  importance. 

An  ophthalmoscopic  examination  of  an  eye  may  show 
the  optic  disc  to  be  the  seat  of  simple  hypercemia,  ance- 
mia,  ischazmia,  or  congestion  and  effusion  within  and 
around  it ;  of  inflammation  of  its  sheath  or  of  its  sub- 
stance ;  and,  lastly,  of  atrophy. 

It  may  show  the  retina  to  be  the  seat  of  hyperazmia, 
anaemia,  of  fatty  exudation  patches,  or  of  haemorrhages. 

It  may  show  the  choroid  to  have  partially  or  alto- 
gether lost  its  pigment  and  to  be  the  seat  of  haemor- 
rhages, to  have  undergone  atrophy,  etc. 

It  may  show  the  blood  vessels  within  the  eye  di- 
minished, obstructed,  dilated,  tortuous,  varicose,  pulsat- 
ing, or  to  be  the  seat  of  embolism,  thrombosis,  or  rupture. 


OPHTHALMOSCOPE.  253 

Hyperemia  of  the  Disc  may  occur  in  the  vessels  of 
the  disc,  in  the  retinal  veins,  or  in  both  retina  and  pa- 
pillae together.  The  larger  vessels,  and  chiefly  the  ret- 
inal veins,  are  seen  dilated,  darker  in  color  than  natu- 
ral, slightly  tortuous,  or  even  varicose. 

To  pronounce  upon  slight  hyperaemia  of  the  disc  or 
retina  is  a  delicate  and  difficult  task  ;  generally  the 
hyperaemia  is  to  be  first  seen  on  the  inner  half  of  the 
disc.  In  states  of  hypersemia,  when  pressure  is  made 
on  the  ball  of  the  eye,  pulsations  in  the  veins  are  more 
marked  than  in  the  normal  condition.  Direct  exami- 
nation is  important  in  these  cases. 

Clinical  Significance  of  Hyperaimia  of  the  Disc  or 
Retina. — Its  causes  are  many.  First,  it  is  frequent  in 
the  first  stage  of  ischaemia,  of  neuritis,  or  of  an  atrophic 
process.  It  may  be  due  to  orbital  disease,  to  choroi- 
ditis, to  BrigmVs  disease,  to  alcoholismus,  to  cerebral 
tumors,  to  acute  or  chronic  meningitis,  and  to  active 
cerebral  hypersemia  ;  transient  hyperaemia  may  be  seen 
in  forms  of  cardiac  disease  which  obstruct  the  venous 
circulation,  and  in  Grave's  disease. 

Anaemia  of  the  Disc  and  Retina  is  the  opposite  of 
hyperaemia.  It  is  always  accompanied  by  anaemia  of 
the  retina  and  choroid.  It  is  liable  to  be  mistaken  for 
atrophy  of  the  disc ;  but  the  edges  of  the  disc  are  not 
so  sharp  and  well  defined  as  in  atrophy,  and  it  is  pos- 
sible to  distinguish  the  arteries  from  the  veins  ;  again, 
anaemia  is  equal  in  both  eyes,  atrophy  is  not ;  besides, 
atrophy  rarely  involves  a  whole  disc  equally,  as  does 
anaemia. 

Clinical  Significance. — The  causes  of  anaemia  of  the 
disc  or  retina  are  the  same  as  those  of  general  or  local 
anaemia. 

Ischemia  of  the  Disc  is  a  mechanical  venous  conges- 


254  PHYSICAL   DIAGNOSIS. 

tion,  oedema,  and  punctate  extravasation  of  the  disc  ; 
the  disc  is  swollen,  rising  abruptly  on  one  side  and  sink- 
ing gradually  on  the  other  ;  its  color  varies  from  a  bright 
transparent  gray  to  a  dirty  red  ;  the  margin  of  the  disc 
is  wholly  concealed  by  infiltration  and  excessive  vascu- 
larity, which  gives  it  a  mossy  appearance  ;  the  veins  of 
the  retina  are  tortuous — they  may  be  very  tortuous. 

It  is  difficult  and  sometimes  impossible  to  distinguish 
this  condition  from  optic  neuritis  ;  the  two  are  fre- 
quently associated. 

Clinical  Significance. — The  causes  of  ischsemia  of  the 
disc  are  all  those  changes  within  the  skull  which  more 
or  less  directly  distend  the  ophthalmic  veins.  The  three 
main  causes  are,  chronic  meningitis,  hydrocephalus,  and 
tumors. 

The  lesions  of  the  optic  disc  which  seem  to  have  the 
closest  connection  with  cerebral,  spinal,  and  general 
diseases  are  hypercemia  and  anosmia  of  disc  and  retina, 
optic  neuritis  with  its  consecutive  atrophy,  and  primary 
or  progressive  atrophy. 

In  Optic  Neuritis  the  disc  becomes  larger  than  usual, 
its  edges  indistinct,  irregular,  and  puffy,  the  infiltration 
casting  a  veil  over  it,  so  as  to  change  its  color  into  a 
lilac  gray,  and  more  or  less  to  conceal  the  vessels  as 
they  pass  within  its  margin.  The  veins  increase  in 
size,  become  tortuous  or  even  varicose  ;  they  darken  in 
color  and  seem  to  be  gorged  with  blood.  The  capilla- 
ries, which  in  their  normal  state  ought  not  to  be  seen, 
also  become  evident,  and  give  a  mossy  or  woolly  ap- 
pearance to  the  disc  (Von  Graefe). 

Clinical  Significance. — Optic  neuritis  is  very  gene- 
rally coexistent  with  meningitis  at  the  base  of  the 
brain,  with  cerebral  tumors  and  large  cerebral  haemor- 
rhages. 


OPHTHALMOSCOPE.  255 

It  can  only  be  distinguished  from  the  ret  i  no-neuritis 
of  albuminuria,  and  from  the  retino-choroiditis  of 
syphilis,  by  the  history  of  the  case,  by  its  limitation  for 
the  most  part  to  the  papilke  and  the  conveying  vessels. 
Its  resemblance  to  ischsemia  has  already  been  stated. 

In  the  consecutive  atrophy  of  optic  neuritis,  the  in- 
tense vascularity  in  and  about  the  disc  subsides,  the  in- 
filtrations are  absorbed,  the  nerve  whitens,  and  the 
capillaries  slowly  shrivel  and  vanish.  The  edges  of  the 
disc  become  distinct  but  are  deformed,  and  patches  of 
organized  lymph  are  to  be  seen  upon  and  about  them. 

In  progressive  atrophy  of  the  optic  disc,  the  fine  ca- 
pillaries which  give  the  rose  tint  to  the  healthy  disc 
slowly  disappear,  and  a  dead  or  pearly  white  is  left. 
The  border  of  the  disc  is  sharp,  clearly  defined,  flat,  and 
even. 

This  lesion  generally  depends  upon  some  disease  of 
the  cerebrum,  cerebellum,  or  spinal  cord. 

The  most  important  indications  of  organic  disease  ca- 
pable of  being  recognized  by  an  ophthalmoscopic  exami- 
nation of  the  eye  have  been  summed  up  by  Dr.  T.  C. 
Allbutt  as  follows  : 

In  the  first  stage  of  meningitis  there  is  dilatation  of 
the  veins  of  the  retina,  peripapillary  congestion,  and 
often  external  effusion.  In  the  second  stage  the  veins 
become  tortuous,  thrombotic,  and  sometimes  rupture. 

In  basilar  meningitis  optic  neuritis  is  present,  but  not 
in  meningitis  of  the  convexity. 

Intercranial  affections  which  directly  distend  the 
ophthalmic  veins,  as  hydrocephalus  and  intracranial 
tumors,  cause  ischaemia  of  the  discs,  and,  if  the  pres- 
sure is  extreme,  atrophy  of  the  optic  nerves. 

Acute  and  chronic  cerebral  softening  causes  acute  or 
chronic  optic  neuritis   and  atrophy.     Cerebral  haenior- 


256  PHYSICAL    DIAGNOSIS. 

rhage,  when  large,  by  its  obstruction  causes  stasis  in 
the  vessels  and  effusion  in  and  about  the  optic  disc. 

In  diseases  of  the  spinal  cord,  as  progressive  atrophy, 
sclerosis,  and  chronic  myelitis,  simple  progressive  atro- 
phy of  the  optic  disc  is  not  uncommon. 

In  Brighfs  disease  the  nutrition  of  the  optic  nerve, 
as  well  as  that  of  the  retina,  is  interfered  with  ;  upon 
the  retina  extravasations  are  seen  in  the  course  of  the 
vessels  ;  these  extravasations  are  slowly  effused  and 
pass  into  degenerative  states,  forming  white  patches  or 
striations  along  the  margins  of  the  veins  ;  most  of  these 
patches  have  evidently  been  clots  ;  some  may  be  due  to 
the  degeneration  of  retina. 

In  syphilis  the  choroid  is  the  chief  seat  of  lesion,  and 
patches  of  many  colors  are  to  be  seen  at  the  back  of 
the  eye  ;  some  of  brilliant  white  and  others  of  darker 
tints,  as  red  or  brown.  We  also  have  intense  neuro- 
retinitis  in  syphilis,  but  its  appearances  cannot  positively 
be  distinguished  from  those  of  any  other  forms  of  neuro- 
retinitis. 

TJiermometer. 

The  thermometer  is  now  regarded  an  indispensable 
mechanical  aid  in  the  diagnosis  of  disease.  I  prefer  (and 
would  recommend  to  you)  the  straight,  self -registering 
clinical  thermometer  represented  in  Fig.  85. 

This  thermometer  consists  of  a  glass  stem,  having  on 
it  a  graduated  scale  varying  from  95°  to  112°  F.,  ex- 
hibiting .2°  F.  The  upper  extremity  of  the  stem  is 
closed.  At  the  lower  end  there  is  a  bulb  of'  mercury  as 
thick  as  the  diameter  of  the  stem.  Within  the  stem  is  a 
bit  of  mercury,  detached  from  that  in  the  bulb,  called  the 
index  ;  this  index  is  set  by  taking  the  bulb  and  stem  of 
the  instrument  firmly  in  the  hand,  when,  by  repeated 


THERMOMETER.  25? 

sudden  blows  of  the  wrist  upon  the  knee,  the  index  is 
brought  down  the  stem  to  a  point  just  below  the  lines 
which  indicate  the  degrees.  After  the  index 
has  thus  been  set,  the  bulb  of  the  instrument 
may  be  applied  to  the  axilla,  between  the 
thighs,  in  the  mouth,  rectum,  or  vagina,  or  to 
any  part  where  it  can  be  completely  covered. 1 
Before  introducing  the  bulb  it  is  well  to  hold 


it  in  the  closed  hand  until  the  mercury  shows 
a  temperature  of  9S°.  Neglect  of  this  precau- 
tion is  apt  to  lead  to  an  under-statement  of 
temperature.  When  the  instrument  has  been 
in  perfect  contact  with  the  parts  for  five  or 
seven  minutes,  gently  remove  it,  and  the  top 
of  the  index  will  denote  the  maximum  tem- 
perature of  the  part.  The  patient  should  be  in 
bed  one  hour  before  the  temperature  is  taken. 

If  the  axillary  temperature  is  to  be  taken, 
the  axilla  should  first  be  thoroughly  dried,  and 
the  bulb  of  the  instrument  placed  directly 
beneath  the  fold  of  the  pectoralis  major  mus- 
cle, the  forearm  on  that  side  being  carried 
across  the  chest,  and  the  elbow  held  by  the 
other  hand  of  the  patient  or  by  an  assistant.        fig.  85.- 

If  the  rectal  or  vaginal  temperature  is  to    Eegfetering 
be  taken,  the  parts  should  first  be  thoroughly  Thermometer- 
cleansed   with  warm  water,  and  the  patient  placed  on 
the  side. 


1  Dr.  E.  Seguin,  of  this  city,  has  devised  a  thermometer  for  de- 
termining localized  surface  temperatures.  The  peculiarity  of  this 
instrument  is  that  the  mercurial  bulb  is  flattened,  so  as  to  furnish 
a  large  surface  at  its  base.  Dr.  Seguin  claims  for  this  instrument 
facility  and  accuracy  in  determining  the  surface  temperature  of 
different  parts  of  the  body. 


258  PHYSICAL   DIAGNOSIS. 

The  mouth  is  the  least  reliable  place  at  which  the 
temperature  can  be  taken,  for  the  temperature  in  this 
cavity  is  constantly  varying  according  to  the  quantity 
and  temperature  of  the  respired  air. 

Thermometrical  observations,  if  possible,  should  be 
continuous,  and  be  taken  at  least  twice  in  the  twenty- 
four  hours — from  7  to  9  a.m.  and  from  4  to  7  p.m. 

In  cases  of  doubtful  diagnosis,  and  in  very  active  dis- 
ease, they  also  should  be  taken  at  noon  and  at  midnight. 

The  pulse  and  number  of  respirations  should  be  noted 
at  the  time  the  temperature  is  taken.  The  rate  of  rise 
in  the  temperature  indicates  the  degree  of  heat,  and 
should  be  noted. 

Range  of  Temperature  in  Health. — The  normal 
temperature,  taken  in  any  of  the  above-named  localities, 
varies  from  9^.5°  F.  to  98.4°  F.  Any  rise  above  99.5°  F., 
or  depression  below  97.3°  F.,  if  persistent,  is  a  sure 
index  of  disease.  A  temporary  elevation  takes  place 
after  meals  and  after  violent  exercise. 

But  there  is  a  diurnal  variation  of  temperature  amount- 
ing to  one  degree  usually,  sometimes  two.  The  mini- 
mum occurs  between  2  and  6  in  the  morning,  and  from 
that  time  there  is  a  rise  until  the  maximum  is  reached 
between  5  and  8  in  the  evening. 

Ranges  op  Temperature  in  Disease. — The  greatest 
range  of  temperature  in  disease  is  17.0°  F.,  the  mini- 
mum being  about  95°  F.,  and  the  maximum  112.55°  F. 
The  highest  recorded  temperature  was  made  by  Wun- 
derlich.  The  highest  temperature  ordinarily  met  with 
in  severe  and  fatal  cases  rarely  exceeds  107°  F. 

A  single  thermometrical  observation  is  an  important 
element  in  differential  diagnosis  when  taken  in  connec- 
tion with  other  symptoms,  but  it  has  no  independent 
diagnostic  value. 


THERMOMETER.  259 

Axillary  temperature  below  100°  F.  excludes  the  ex- 
istence of  fever ;  above  101°  F.,  leads  to  the  probability 
of  fever;  when  it  exceeds  108°  F.,  you  may  probably 
exclude  fever. 

A  temperature  of  107°  F.  indicates  malignancy,  and 
when  met  with  for  two  consecutive  days  in  typhus, 
scarlatina,  measles,  pneumonia,  pyaemia,  meningitis,  or 
rheumatic  affections,  death  is  almost  certain  to  follow. 
In  relapsing  and  in  pernicious  intermittent  fevers,  the 
temperature  may  rise  to  107°  without  indicating  great 
danger. 

In  many  diseases,  during  the  last  few  hours  of  life,  the 
temperature  suddeDly  rises  as  high  as  109°  F.,  or  even 
111°  F.  ;  especially  is  this  true  in  tetanus,  sunstroke, 
typhus,  pyaemia,  etc.  A  temperature  below  98°  does 
not  necessarily  indicate  collapse,  but  is  more  likely  to 
be  met  with  in  the  aged  and  feeble  when  subjects  of 
grave  disease. 

Thus  it  is  evident  that  a  given  temperature  without 
its  antecedents  is  apt  to  mislead  in  diagnosis.  When 
isolated,  the  highest  temperature  only  portends  danger, 
and  with  a  temperature  of  95°  F.  collapse  is  not  cer- 
tain. 

Daily  Variation  of  Temperature  in  Disease. — 
Daily  thermometrical  variations  in  disease  depend  upon 
the  elements  which  constitute  the  morbid  processes,  the 
intensity  of  these  processes,  and  the  stage  they  have 
reached;  also  somewhat  on  the  idiosyncrasy  of  the 
patient. 

A  single  day's  variations  may  determine  the  severity 
and  stage  of  a  disease  ;  but  you  must  compare  the  vari- 
ations of  a  number  of  days  before  (in  a  large  proportion 
of  cases)  you  can  reach  a  diagnosis. 

High  average  temperature,  above  104°  F.,  is  met  with 


260  PHYSICAL   DIAGNOSIS. 

in  remittent,  typhus,  typhoid,  and  relapsing  fevers,  in 
severe  pneumonia,  etc. 

A  moderately  high  average  temperature  above  102°  F. 
is  met  with  in  catarrhs,  cerebro-spinal  meningitis,  diph- 
theria, dysentery,  pleurisy,  pericarditis,  acute  rheuma- 
tism, peritonitis,  etc. 

A  slight  average  rise  in  temperature  above  100°  F. 
has  a  varied  significance,  and  is  met  with  in  a  large 
class  of  chronic  affections,  and  at  the  commencement  of 
acute  inflammations  and  mild  types  of  fever. 

When  your  thermometrical  observations  follow  regu- 
lar diurnal  variations,  with  a  rise  each  day  of  one  de- 
gree— as,  first  day,  morning  99.5°  F.,  evening  101.5° 
F. ;  second  day,  morning  100.5°  F.,  evening  102.5°  F.; 
third  day,  morning  101.5°  F.,  evening  103.5°  F. — you 
have  almost  certain  evidence  of  typhoid  fever.  If  the 
temperature  does  not  exceed  on  any  evening  103.5°  F., 
the  fever  will  probably  have  a  mild  course  ;  if  it  reaches 
105°  F.  in  the  evening,  it  shows  that  the  attack  is  a  se- 
vere one,  and  forebodes  danger.  A  sudden  and  marked 
reduction  of  temperature  to  95°  F.  during  the  third 
week  of  typhoid  fever,  denotes  haemorrhage  from  the 
sloughs  of  Peyer's  patches. 

If  a  patient  with  measles  retain  a  high  temperature  af- 
ter the  eruption  has  faded,  it  indicates  some  ccmplication. 

Whatever  differences  of  opinion  may  exist  in  regard 
to  the  importance  and  reliability  of  thermometrical  ob- 
servations as  elements  of  diagnosis,  the  following  propo- 
sitions, it  seems  to  me,  may  be  regarded  as  established  : 

1.  An  abnormal  temperature  denotes  the  presence  of 
some  disturbance  in  the  animal  economy. 

2.  Certain  degrees  of  temperature  indicate  fever. 

3.  The  height  of  the  temperature  decides  the  severity 
and  danger  of  a  disease. 


MICROSCOPE.  261 

i.  Thermometrical  observations  aid  us  in  discovering 
the  laws  which  regulate  the  course  of  certain  diseases. 

5.  When  the  normal  thermometrical  course  of  a  dis- 
ease has  been  determined,  its  diagnosis  is  simplified. 

6.  The  thermometer  indicates  quickly  and  certainly 
any  deviation  in  the  regular  course  of  many  diseases, 
the  transition  from  one  stage  to  another,  and  the  com- 
mencement of  convalescence. 

7.  It  reveals  the  occurrence  of  complications. 

8.  It  often  reveals  the  imminence  of  a  fatal  termi- 
nation. 

9.  It  sometimes  shows  the  impossibility  of  the  con- 
tinuance of  life. 

10.  It  is  an  important  guide  as  regards  the  effects  of 
remedial  agents. 

Microscope. 

The  compound  microscope  consists  essentially  of  a 
tube  (T)  having  a  system  of  lenses  at  each  end  ;  the  up- 
per system  is  called  the  ocular  (Oc),  the  lower  the  ob- 
jective (Obj).  Within  this  is  a  smaller  or  draw  tube. 
The  whole  is  attached  to  the  stand  (S).  At  St  is  the  stage 
on  which  the  object  to  be  examined  is  placed.  In  its 
centre  is  a  diaphragm  for  the  purpose  of  regulating  the 
amount  of  light.  Below  the  stage  a  mirror  (M),  with  a 
plane  and  concave  surface,  is  suspended.  It  is  for  the 
purpose  of  illuminating  the  specimen,  and  is  so  adjusted 
as  to  admit  of  movement  in  any  direction.  The  lenses  are 
focussed  by  means  of  the  coarse  (C.  adj)  and  fine  (F.  adj) 
adjustments.  The  coarse  adjustment  has  a  rack-and- 
pinion  movement  ;  the  fine  adjustment  consists  of  a 
finely  cut  screw  acting  against  a  spring.  There  should 
be  at  least  two  objectives — a  low  power  having  a  focal 
distance  of  half  an  inch,  and  a  high  power  with  a  focal 


262 


PHYSICAL   DIAGNOSIS. 


distance  of  one-sixth  of  an  inch.  For  bacteriological 
work  a  homogeneous  oil-immersion  lens  (one-twelfth) 
is  required. 

A  good  microscope  should  magnify  from  fifty  to  four 
hundred  linear  diameters. 

Method  of  Using  the  Mi- 
croscope.— For     the     exami- 
nation of  blood,    pus,    urine,1 
etc.     (for    sputum    see     page 
207),    all  that   is   necessary  is 
to  place  a  drop  of  the   speci- 
men in  the  centre  of  a  slide, 
cover  it   with   a  cover    glass, 
and  put  it  under  the  micro- 
scope.   Small  pieces  of  tumors, 
and  curettings  from  the   ute- 
rus and  cervix  uteri,  may  be 
teased  out  on  a  slide  with  fine 
needles  and  examined  for  their 
component  cells.     But  when  it 
is  remembered  that  a  diagnosis 
is    based    in    many   instances 
upon  the  arrangement  as  well 
as  the  appearance  of  the  cells, 
it  will  be  seen  that  this  method 
is  open  to   serious   objections. 
Tissues  should  always  be  hard- 
ened, embedded,  and   cut  into  thin  sections.     The  sec- 
tions should  then  be   stained  and   mounted.     For  the 
methods  of  hardening,  staining,  etc.,  the  student  is  re- 
ferred to  Stirling's  Practical  Histology." 


Fig.  86— The  Microscope. 


1  For  obtaining-  the  sediment  from  -urine,  it  is  convenient  to  close 
the  upper  end  of  a  pipette  with  the  finger,  pass  its  tip  down  through 
the  urine,  and  then  remove  the  finger. 


DYNAMOMETER. 


263 


Dynamometer. 

The  best  dynamometer  is  that  of  M.  Mathieu,  an  in- 
strument maker  of  Paris.  It  is  very  simple,  and  for 
measuring  the  strength  of  the  hands  leaves  nothing  to 
be  desired. 

It  consists  (as  shown  in  Fig.  8T)  of  an  elliptical 
steel  spring,  to  which  is  attached  a  semicircle  of  brass 
upon  which  a  scale  is  marked.  The  indicator  termi- 
nates at  its  central  end  in  a  cogwheel  which  works 
upon  a  steel  arm.  When  it  points  to  zero  of  the  scale, 
the  lower  end  of  the  arm  touches  the  elliptical  spring. 
A  brass  sheath  upon  the  under  side  of  the  scale  keeps 


Fig.  87. — Dynamometer. 

this  arm  in  place,  at  the  same  time  allowing  it  to  move 
freely. 

"When  the  dynamometer  is  grasped  in  the  hand,  and 
the  two  sides  of  the  spring  approximated,  the  indicator 
is  turned  by  the  upward  movement  of  the  arm.  One 
great  advantage  of  this  instrument  is  that,  when  the 
pressure  is  taken  off,  the  indicator  does  not  return  to 
zero,  but  remains  at  the  point  to  which  it  has  been  car- 
ried by  the  muscular  power  of  the  individual. 

Clinically,  you  are  able  to  measure  the  strength  of 
partially  paralyzed  muscles  of  the  upper  extremities, 
to  determine  the  slightest  difference  in  the  muscular 
power  of  the  two  hands,  as  well  as  to  determine  any 
changes  that  may  occur  from  time  to  time  in  the  course 
of  a  case  of  paralysis. 


264 


PHYSICAL   DIAGNOSIS. 


uEsthesiometer. 

This  instrument  was  invented  by  Dr.  Sieveking  in 
1858  for  the  purpose  of  determining  the  degree  of  tac- 
tile sensibility  of  any  part  of  the  body. 

It  consists  of  a  graduated  bar  of  metal  four  or  five 
inches  in  length.  At  one  end  is  a  fixed  steel  point. 
Another  steel  point  is  made  to  slide  upon  the  bar,  and 
can  be  fixed  at  any  distance  from  the  first  by  a  screw 
which  works  at  the  top  of  the  slide  (Fig.  8S). 

It  will  be  found  that  in  a  perfectly  healthy  person, 
when  two  impressions  are  simultaneously  made  upon 
the  skin,  the  power  of  distinguishing  them  varies 
greatly  in  different  parts  of  the  body. 


Fig.  88  —  JEsthesiometer. 

The  following  table  of  Weber  gives  the  distances  at 
which  the  two  points  of  the  sesthesiometer  are  normally 
felt  in  the  different  regions  of  the  body  : 

Tip  of  the  tongue 1.1 

Palm  of  distal  phalanx  of  finger. .    2.2 

Palm  of  second  phalanx  of  finger 4.4 

Tip  of  nose G.  6 

White  portion  of  the  lips 8.8 

Back  of  second  phalanx  of  finger 11.1 

Skin  over  the  malar  bono 15.4 

Back  of  the  hand 29.S 

On  the  forearm 39.  G 

On  the  sternum 44. 0 

On  the  back 66.0 


EXPLORING   TROCAR.  265 

In  using  the  instrument,  first  fix  the  two  points  at 
the  distance  which  is  normal  for  the  part  of  the  skin  to 
be  inquired  into.  The  points  must  be  applied  simulta- 
neously.1 If  the  patient  feels  only  one  point  when 
both  points  touch  the  skin,  the  two  points  must  be 
gradually  separated  from  each  other,  and  reapplied  to 
the  part  until  both  points  are  felt  ;  in  this  way  you  will 
determine  the  amount  of  ancesthesia  present.  If,  on 
the  other  hand,  the  two  points  are  each  distinctly  felt  at 
the  normal  distance  limit,  they  must  be  brought  gradu- 
ally toward  each  other  until  one  point  is  felt  ;  thus 
you  determine  the  amount  of  hyperesthesia  present. 

The  patient  ought  not  to  see  the  instrument,  or  know 
for  what  purpose  it  is  applied. 

This  instrument  aids  you  in  determining  the  amount 
and  extent  of  sensational  impairment  in  cases  of  paraly- 
sis, as  well  as  for  determining  if  the  loss  of  sensation  is 
progressive.     In  the  record  of  cases  it  is  also  of  service. 

Exploring  Trocar. 

This  instrument  is  an  aid  to  positive  diagnosis,  as  it 
enables  you  to  determine  the  character  of  fluid  contained 
in  a  distended  pleural,  pericardial,  or  abdominal  cavity, 
or  of  that  contained  in  any  fluctuating  tumor  or  deep- 
seated  abscess. 

There  are  three  instruments  which  may  be  used  as 
exploring  trocars,  viz. :  the  ordinary  Hypodermic  Sy- 
ringe, Dieulafoy''s  Aspirator,  and  Dieulafoy,s  Exhaust- 
ing Syringe. 

The  objection  to  the  hypodermic  syringe  is  that  the 
needles  are  so  small,  and  the  exhausting  power  of  the 

1  Care  must  be  taken  not  to  press  too  heavily,  or  the  sensation  of 
two  points  will  be  converted  into  the  sensation  of  one. 


366 


PHYSICAL    DIAGNOSIS. 


syringe  so  slight,  that  you  are  not  always  able  to  draw 
the  fluid  through  them. 

The  Aspirator  is  the  best  instrument  for  the  purpose, 
but  its  price  places  it  beyond  the  reach  of  many. 

The  Exhausting  Syringe  is  much  larger  than  the  hypo- 
dermic syringe.  It  consists  of  a  glass  cylinder  encased  in 
a  metal  mounting,  which  is  fenestrated  so  that  the  fluid 
can  be  seen  as  it  is  drawn  into  the  syringe.  There  are 
two  branches  upon  which  the  needles  may  be  fitted.  A 
valve  is  placed  at  their  junction,  and  connected,  by  means 
of  small  bars  and  joints,  with  a  handle  running  along  the 


Fig.  89.— Dieulafoy's  Exhausting  Syringe 

side  of  the  cylinder.  When  the  handle  is  depressed,  the 
valve  rotates,  closing  one  of  the  branches  ;  when  the 
pressure  is  taken  off,  a  spring  returns  the  handle  to  its 
former  position,  the  valve  closing  the  branch  previously 
opened  (see  Fig.  89).  By  this  means  the  entrance  of  air 
into  the  needle  is  prevented. 

Two  needles  accompany  the  instrument — a  large  and 
a  smaller  one ;  the  former  to  be  used  when  pus  is  sus- 
pected, the  latter  when  you  expect  to  find  serum. 

The  needles  are  first  introduced  into  the  part  to  be 
examined,  and  then  connected  with  the  syringe,  either 
directly  or  by  means  of  a  small  rubber  tube. 


SPECULA.  2G7 

Dr.  Dieulafoy,  of  Paris,  the  inventor  of  this  instru- 
ment, says  that  it  is  always  possible  to  introduce  the 
needle  without  danger  in  searching  for  fluid,  no  matter 
where  it  is  situated  or  what  its  nature,  and  that  he  has 
never  met  with  an  accident  in  using  it. 

If,  after  obtaining  the  fluid,  any  doubt  remains  as  to 
its  character,  a  drop  should  be  placed  on  a  slide  and  ex- 
amined under  the  microscope.  The  diagnostic  value  of 
such  an  instrument  is  so  readily  appreciated  that  it  is 
not  necessary  to  enter  into  the  details  of  its  application. 

Specula. 

Various  specula  have  been  devised  for  exploring  the 
nose,  the  ear,  the  vagina,  the  rectum,  and  the  urethra, 
and,  in  the  hands  of  those  accustomed  to  their  use,  are  of 
material  aid  in  arriving  at  a  more  positive  diagnosis  than 
could  otherwise  be  obtained. 

The  endoscope,  an  instrument  constructed  for  the  pur- 
pose of  exploring  and  making  applications  to  the  urethra, 
bladder,  and  rectum,  has  a  series  of  dark-lined  metallic 
tubes,  which  are  employed  as  specula,  and  may  be  used 
with  solar  or  artificial  light.  The  uses  of  this  instrument 
are  almost  exclusively  confined  to  the  domain  of  surgery; 
I  shall  not,  therefore,  include  it  in  the  list  of  mechanical 
aids  to  medical  diagnosis. 


IKDEX. 


Abbe,  205 
Abdomen,  129 

difficulties  of  physical  exami- 
nation, 131,  138 
epigastric  zone,  132 
hypogastric  zone,  133 
methods  of  physical  examina- 
tion, 135 
umbilical  zone,  132 
zones  of,  132 
Abdominal  aneurism,  errors  in  di- 
agnosis of,  169 
aneurism,  murmur  in,  169 
aneurism,  physical  signs,  168 
tumors,    diagnosed  from  ab- 
dominal aneurism,  170 
Abnormal  or  adventitious  sounds, 

40 
Abscess,    chronic,    of    abdominal 
wall,  diagnosed    from    en- 
larged spleen,  155 
of  liver,  physical  signs,  148 
Absent  or  suppressed  respiration, 

35 
Actinomyces  in  sputum,  213 

in  urine,  227 
Acute  hepatitis,    physical    signs, 
149 
lobar  pneumonia,  58 
peritonitis,  139 
pleurisy,  66' 

tubercular  pneumonia,  75 
^Esthesiometer,  description  of,  264 
table  of  normal  distances,  264 
Albumin  in  urine,  tests  for,  187 
in    urine,   pathological  states 

in  which  it  appears,  189 
in  urine,  significance  of,  189 
Albuminometer.  188 
"  Alveolar"  cells,  207 
Ammonio-magnesium    phosphate 

in  urine,  218 
Ammonium  urate,  215 
Amoeba  coli  in  faeces,  231 
in  sputum,  215. 


Amphoric  cough,  51 

resonance,  26 

respiration,  38 

voice,  50 
Anchylostoma  duodenale,  ova  of, 

232 
Aneurism  of  arteria  innominata, di- 
agnosis, 125 

of  thoracic  aorta,  differential 
diagnosis,  124 

of    thoracic    aorta,    physical 
signs,  121-124 

of  thoracic  aorta,  statistics,  121 
Anterior  rhinoscopy,  243 
Anthrax,  bacillus  of,  205 
Aorta,  course  of  arch,  83 

thoracic,  aneurism,  121 

topography  of,  81 
Aortic    regurgitation,     sphygmo- 
graph  in,  247 

stenosis,  sphygmograph  in, 248 

valves,  82 
Arteria  innominata,  aneurism  of, 

diagnosis,  125 
Ascaris  lumbricoides,  ova  of,  232 
Ascites,    diagnosis  from    ovarian 
dropsy,  167 

physical  signs,  139 
Asthma,  spasmodic,  57 
Asystolism,  119 

Atheroma,  sphygmograph  in,  248 
Atrophy  of  liver,  152 
Auricular  diastole,  84 

systole,  84 
Auscultation,  29 

elements  of,  31 

immediate,  29 

intra-thoracic,  39 

mediate,  29 

rules  for,  30 

of  voice,  47 

of  voice  in  health,  47 
Auscultatory  percussion,  27 

percussion,    benefits    claimed 
for,  27 

percussion,    method    of    per- 
forming, 27 


370 


INDEX. 


Auscultatory  percussion,    stetho- 
scope for.  '17 
Axillary,  infra-,  region,  10 
region,  10 
region,  superior  and  middle, 

percussion  of,  23 
temperature,  256 


Bacillus  of  anthrax,  205 
of  Eberth,  231 
of  typhoid  fever,  207 
"  Barrel-shaped  "  chest,  13 
Bennett,  27 
Bile  in  urine,  193 

in  urine,  effect  on  color,  178 
Gmelin's  test  for,  193 
Pettenkofer's  test  for,  193 
Bladder,  159 
Blood,  anthrax  bacilli  in,  205 

bacillus  of  typhoid  fever  in, 

207 
casts,  225 
changes  in  form,  etc.,  of  .red 

cells,  202 
changes,  significance  of,  203 
diminution  in  number  of  red 

cells,  200 
examination  of,  199 
in  faeces,  229 
filaria  sanguinis    hominis  in, 

207 
increase  in  number  of  white 

cells,  201 
method  of   determining  pre- 
sence in  vomit,  228 
method  of   obtaining  for   ex- 
amination, 199 
Plasmodium  malariae,  207 
plates,  200 
red  corpuscles,  199 
spirillum  of  relapsing  fever, 

204 
in  sputum,  208 
tubercle  bacillus  in,  207 
in  urine,  194 

in  urine,  effect  on  color,  178 
in  urine,  microscopical  exami- 
nation, 221 
white  corpuscles,  200 
Botliriocephalus  latus,  ova  of,  232 
Breathing,  normal,  11 
Brieger,  219 
Bright,  132,  147,  156 
Bright's   disease,  specific    gravity 

in,  180 
Bronchi,  dilatation  of  (bronchiec- 
tasis), 54 
Bronchial  casts,  209 
cough, 51 
respiration,  33,  37 


Bronchitis,  acute  and  chronic,  of 
larger  tubes,  53 
capillary,  54 
Bronchophony,  normal,  47 
Bruit,  uterine,  161 


Calcium  oxalate  in  urine,  217 

phosphate    and    carbonate  in 

urine,  216 
phosphate  in  urine,  219 
Cammann,  27,  30,  235,  2H8 
Cancer  of    liver,    physical  signs, 
149,  150 
of  omentum,  diagnosed  from 

enlarged  spleen,  155 
pulmonary,  63 
of  stomach,  142 
of  stomach,   diagnosed  from 
enlarged  spleen,  155 
Carbolic  acid,  effect  on   color   of 

urine,  178 
Cardiac  cycle,  84 

duration  of  different  phases, 

86 
dilatation,  118 
hvpertrophy,   physical  signs, 

"115 
hypertrophy  with  dilatation, 

117 
sounds,  simulating  murmurs, 
111 
Cardiometer,  description  of,  238 
Casts  in  urine,  223 
Cavernous  cough,  51 

respiration,  37 
Cavities,  pulmonary,  causation,  44 
Changes  of  normal  respiration,  34 
Chest,  "  barrel-shaped,"  13 
bulging  of,  14 
deficiency  of  expansion,  17 
dimensions  of,  17 
healthy  alterations  in  form,  12 
sinking  in,  14 

surface  of,   division  into  re- 
gions, 4 
Chloride  of  sodium,  clinical  signi- 
ficance in  urine,  186 
Cholera  bacillus,  230 
Chronic  abscess  of  abdominal  wall 
diagnosed    from    enlarged 
spleen.  151). 
peritonitis,  139 
Chyluria.  216 

(condition  of  urine),  178 
Cirrhosis  of  liver,  151 
Clark,  27 

Clavicular,  infra-,  region,  5 
region, 4 

region,  percussion  of,  23 
supra-,  region,  4 


INDEX. 


271 


"  Cogged-wheel "  respiration,    35, 

76 
Comma  bacillus,  230 
Congestion  of  liver,  physical  signs, 
149 

pulmonary,  64 
Costal  breathing,  11 
Cough,  amphoric,  51 

bronchial,  51 

cavernous  (sepulchral),  51 

resonance  of,  51 

sepulchral,  51 
Cracked- pot  resonance,  26 
Creosote,  effect  on  color  of  urine, 

178 
Crepitant  rale,  42 
Crystals  in  urine  : 

ammonio-magnesium       phos- 
phate, 218 

ammonium  urate,  215 

calcium  oxalate,  217 

calcium  phosphate,  219 

cystin,  21 9 

leucin,  219 

sodium  urate,  215 

triple  phosphate,  218 

tyrosin,  220 

uric  acid,  217 

xanthin,  220 
Curschmann's  spirals,  208 
Cyrtometer,  description  of,  237 
Cystin  in  urine,  219 


Diabetes  mellitus,  193 

specific  gravity  in,  179 
Diaphragmatic  breathing,  11 
Diastole,  auricular,  84 

ventricular,  85 
Diastolic  venous  murmurs,  128 
Dicrotism,  247 
Dieulafoy's  aspirator,  265 

exhausting    syringe,    descrip- 
tion of,  266 
Dilatation  of  bronchi,  54 

of  heart,  118 
Diminished  or  feeble  respiration, 
35 

vocal  fremitus,  15 
Distoma  hepaticum,  ova  of,  231 
Doremus,  181 
Dropsy,   abdominal,   diagnosis  of 

ovarian  from  ascites,.. L67 
Dulness,  25 
Dynamometer,  description  of,  263 


Eberth,  231 

Echinococci  in  sputum,  215 
in  urine,  227 


Egophony,  49 

Einhorn,  191 

Elastic  tissue  in  sputum,  209 

Emphysema,  inspection  in,  13 

physical  signs,  56 
Empyema,  physical  signs,  70 

pulsatile,  diagnosis  from  aneu- 
rism, 125 
Endoscope,  267 

Enlarged  left  lobe  of  liver,  diag- 
nosed from  enlarged  spleen,  155 
Epigastric    pulsation,     diagnosed 
from  abdominal  aneurism, 
125 

region,  132 

region,  contents  of,  134 

zone,  boundaries  of,  132 

zone,  divisions  of,  132 
Epithelial  casts,  224 
Epithelium  in  faeces,  230 

in  sputum,  207 

in  urine,  2i2 

in  vomit,  229 
Exaggerated      pulmonary      reso- 
nance, 25 

respiration,  34 

vocal  resonance,  49 
Expiratiou,  prolonged,  36 
Exploring  trocar,  265 


Faecal  accumulations,  characteris- 
tics of,  143 

diagnosed    from    disease    of 
liver,  152 

diagnosed      from      enlarged 
spleen,  156 

diagnosed    from    ovarian  tu- 
mors, 167 
Fasces,  229 

amoeba  coli  in,  231 

comma  bacilli  in,  230 

epithelium  in.  230 

micro-organisms  in,  230 

ova  in,  231 

pus  in,  229 

red  blood  corpuscles  in,  229 

tubercle  bacilli  in,  231 

typhoid  bacilli  iu,  231 
Fat  in  urine,  216 
Fatty  casts,  225 

heart,  physical  sigus,  119 

liver,  physical  sigus,  147 
Fehling's  fluid,  190 
Fer mentation  test  for  sugar,  190 
Fibroid  heart,  physical  signs,  119 
Filaria  sanguinis  hominis,  207 

in  urine,  227 
Flatness,  25 
Kleischl.  von,  203 
Flint,  26,  36,  50,  237 


272 


INDEX. 


Foetal  heart  sound,  162 

Frankel,  213 

Fremitus,  changes  in,  15 

friction,  16 

normal  vocal,  15 

ronchial,  16 

sonorous.  16 
Friction  fremitus,  16 

sounds,  pericardial,  97 
Friedlander,  213 
Fuchsm,  210 
Funic  souffle,  162 

G 

Gall  bladder,  position  of,  145 
Gangrene,  pulmonary,  62 
Glycosuria,  193 
Gmelin's  test  for  bile.  193 
Gonococci,  method  of  staining,  226 

in  urine,  226 
Gram,  213 
Granular  casts,  224 
Guaiacum  test  for  blood,  194 
Gurgles,  43 


H 


Hsematuria,  194 

Hsemin  crystals,  228 

Haemoglobi  uria,  194 

Haemorrhage,  pulmonary,  62 

Hare,  16 

Heart,  abnormal  sounds  of,  97 

asystolism,  119 

auscultation  of,  rules  for,  92 

diastole,  auricular,  84 

diastole,  ventricular,  85 

dilatatio  >  of,  118 

fatty,  physical  signs,  119 

fibroid,  physical  signs,  119 

foetal  sounds,  1 62 

hypertrophy  of   115 

hypertrophy  with  dilatation, 
17 

impulse,  change  in  situation 
of,  89 

impulse,  diminution  of  force, 
90 

impulse,  effect  of  respiration 
on,  89 

impulse,  increase  of  force.  90 

impulse,  production  of,  85 

inspection  of,  89 

methods  of  physical  examina- 
tion, 89 

murmur,  rhythm  of,  99 

murmurs,  definition,  97 

palpation  of.  90 

percussion  of,  91 

physiological  nction  of,  83 

"  purring  thrill,"'  91 


Heart,  sounds  of,  85 

sounds,  alterations  in  quality 

and  pitch,  94 
sounds,  alteration  in  rhythm, 

95 
sounds,  alteration  in  seat,  95 
sounds,  diminished  intensity, 

94 
sounds,  increased  intensity,  94 
sounds,  intensity  of,  93 
sounds,  irregularity  in,  95 
sounds,  modifications  of,  94 
sounds,  normal,  93 
sounds,  reduplication  of,  96 
sounds,  rhythm  of,  86,  87 
systole,  auricular,  84 
systole,  ventricular,  84 
topography  of,  81 
valves,  closure  of,  84,  85 
valves,    relative  positions  of, 
82 

Heller's  test,  187 

Henocque,  203 

Hepatitis,acute,physical  signs,  149 

Hippocrates,  19 

Hutchinson,  18 

Hyaline  casts,  223 

Hydatid  tumors  of  liver,  physical 
signs,  150 

Hydatids  in  sputum,  215 

of  omentum,  diagnosed  from 
ovarian  tumors,  167 

Hydro-pneumothorax,  73 

Hypertrophy,    cardiac,     physical 
signs,  115 
cardiac,  with  dilatation,  117 

Hypodermic  syringe  for  explora- 
tion, 265 

Hypogastric  region,  134 
zone,  133 
zone,  subdivisions,  133,  134 


Increased  vocal  fremitus,  15 

Indican  in  urine,  178 

Inferior  sternal  region,  percussion 

of,  23 
Infra-axillary  region,  10 
Infra-mammary  region,   left,  per- 
cussion of,  23 

region,  right, percussion  of,  23 
Infra-scapular  region,  9 
Inspection,  3,  11 

in  pleurisy,  12 

in  pulmonary  emphysema,  13 

in  pulmonary  tuberculosis,  13 
Interrupted  respiration,  35 
Inter-scapular  region,  9 
Intestinal  ova,  231 
Intestines,  fecal  accumulations  in, 
142 


INDEX. 


273 


I ntra-thoracic  auscu  tati  n,  39 
tumors,  diagnosis  from  aneu- 
rism, 124 


Jaksch,  von,  202 


Kidney,  disease  of  left,  diagnosed 
from  enlarged  spleen,  156 

disease  of  right,  diagnosed 
from  disease  of  liver,  152 

enlargement  of,  157 

me  hod  of  determining  en- 
largement, 158 

movable,  159 

normal  boundaries  of,  157 

sources  of  error  in  diagnosis  of 
enlargement,  158 


Laennec,  46,  49 
Laryngeal  image,  241 

mirror,  239 
Laryngophony,  natural,  47 
Laryngoscope,  description  of,  239 
Larynx,  method  of  examining.  240 
Left  hypochondriac  region,  132 

contents  of,  134 
Left  iliac  region,  134 
contents  of,  135 
Left  lumbar  region.  133 

contents  of,  131 
Left  kidney,  disease  of,  diagnosed 

from  enlarged  spleen,  156 
Leucin  in  urine,  219 
Leucocythsemia,  202 
Leucocytosis,  201 
Leukaemia,  202 
Liebreich,  250 
Lipuria,  216 

Liver,  abscess  of,  physical  signs, 
148 
acute  hepatitis,  physical  signs, 

149 
alteration  of  normal   bounda- 
ries in  health,  145 
atrophy  of.  152 
cancer  of,  physical  signs,   119, 

150 
cirrhosis    of,    physical  signs, 

151 
congestion  of,  physical  signs, 

149 
decrease  in  size,  151 
differential  diagnosis  of    dis- 
eases, 152 
diseases  producing  increase  in 
size,  147 


Liver       displacement     diagnosed 
from  disease,  153 
displacement  from  lacing,  1 16 
displacement  of,   in    thoracic 

diseases,  146 
fatty,  physical  signs,  147 
hydatids,  physical  signs,  150 
method  of  determining  boun- 
daries, 144, 145 
normal  boundaries  of,  144 
obstruction  of  bile  ducts,  phy- 
sical signs,  149 
vertical  measurements  of,  145 
waxy,  physical  signs,  147, 148 
Lobular  pneumonia,  60 
Loring,  250 
Lower  sternal  region,  7 

M 

Macrocytes,  202 
Mammary,  infra-,  region,  6 

region,  6 
Marey.  245 
Math'ieu,  263 

Mechanical  aids  to  diagnosis,  235 
Mensuration,  3 

Hare's  method  of  performing, 
16 

method  of  performing,  16 

object  of,  17 
Mesentery,  enlargements  of,  171 
Metallic  tinkling,  51 
Method  of  examining  larynx,  240 
Micrococcus  ureas,  2^6 
Microcytes,  202 
Microcythaemia,  202 
Micro-organisms  in  faeces,  230 

in  urine,  2J6 
Microscope,  description  of,  261 

method  of  using,  262 
Mineral  acids,  effect  on   reaction 

of  urine,  179 
Mitral  valve.  82 
Moist  rales.  42 
Movable  kidney,  159 
Mucous  click,  44 

corpuscles,  221 

cylindroids,  220 

rale,  43 
Mucus  in  urine,  220 
Murchison,  147 
Murexide  test,  183 
Murmur  of  abdo.ninal  aneurism, 
169 

vehicular   32 
Murmurs,  anaemic  and  functional, 
108 

area  of  aortic,  106 

ar  a  of  mitral,  104 

area  of  pulmonic,  105 

area  of  tricuspid,  105 


«74 


IXDEX. 


Murmurs,  cardiac,  definition  of,  97 

cardiac,  number  of,  101 

cardiac,  rh\  thm  of,  99 

cardiac,  seat  of,  103 

d.agnosi;  of,  106 

dia-tolic  venous,  128 

Dr.  Cammaun's  rules  regard- 
ing, 109 

endocardial  or  valvu'ar,  98 

presys1  olic  venous,  127 

rhythm,  rules  for  determin- 
ing. 100 

sub-clavian,  126 

systolic  venous,  127 

table  of  cardiac,  102 

venous,  108,  127 

ventricular,  111 

N 

Normal  alterations  in  form    and 
movements  of  client,  12 
laryngeal  and  tracheal  respira- 
tion, 33 
vocal  fremitus,  15 
vocal  resonance,  47 


Obstruction  of  bile  ducts,  physical 

signs,  149 
(Edema,  pulmonary,  61 
oligocythemia,  200 
Omentum,   cancer    of,   diagnosed 
from  enlarged  spleen,  155 
hydatids  of,  diagnosed  from 

ovarian  tumors,  167 
tubercular  enlargements,  diag- 
nosed from  enlarged  spleen, 
155 
tumors  of.  diagnosis,  170 
Ophthalmoscope,    description    of, 
250 
in  diagnosis,  253-256 
methods  of  using,  251 
Ovarian  dropsy,   diagnosed  from 
ascites,  167 
tumors,   diagnosed  from  dis- 
ease of  liver.  153 
Ovaries,  normal  po-ition.  164 

tumors  of,  differential  diagno- 
sis  166 
tumors  of,  physical  signs,  165 
Oxaluria,  218 


Palpation,  3,  14 
Pectoriloquy,  49 
Penicilium  glaucum,  226 
Percussion,  3,  19 
auscultatory,  27 


Percussion,  duration  of  sound,  20 
elements  of,  19 
immediate,  19 
in  di-ease,  24 
in  health,  22 
intensity  of  sound,  20 
mediate,  19 

method  of  performing,  21 
pitch  of  sound,  20 
quality  of  sound,  20 
rules  for  performing,  21 
variations  in  health,  24 
Pericardial  friction  sounds,  diagno- 
sis of,  98 
friction  sounds. varieties  of,  97 
sac,  position  of,  83 
Pericarditis,  physical  signs  of,  113 
Peritoneum, diseased  conditions  of, 

139 
Peritonitis,  acute,  139 

chronic,  139 
Pettenkofer's  test  for  bile,  193 
Physical  diagnosis,  definition  and 

methods  of,  3 
Physiological  aciion  of  heart,  83 
Pioiry,  19 

Plasmodium  malarias,  207 
Pleurisy,  acute,  differential  diagno- 
sis of,  70 
acute,  stage  of  absorption,  68 
acute,  stage  of  liquid  effusion, 

67 
acute,  stage  of  plastic  exuda- 
tion, 66 
inspection  in,  12 
subacute,  stage  of  absorption, 

64 
subacute,  stage  of  effusion,  68 
varieties  of,  66 
Pleuritic  friction  sounds,  40,  45 

friction  sounds,  varieties  of,  46 
Pleximeter,  21 
Pneumococcus,  213 

method  of  staining,  214 
Pneumothorax,  72 
Pneumonia, acute  lobar, first  stage, 
58 
acute  lobar,  second  stage.  59 
acute  lobar,  third  stage,  59 
acute  tubercular,  75 
inspection  in,  13 
lobular,  60 
Poikilocytes,  203 
Poikilocytosis.  203 
Posterior  rhinoscopy,  243 
Pregnancy,  diagnosis  of ,  160 

diagnosed    from  ovarian    tu- 
mors, 167 
twin,  163 
Presystolic  jugular  pulsation,  127 

venous  murmurs,  127 
Prolonged  expiration,  36 


INDEX. 


275 


Pubic  region,  134 

region,  contents  of,  134 
Pulmonary  artery,  course  of,  83 

cancer,  physical  signs,  153 

cavities,  causation.  44 

collapse,  physical  signs,  64 

congestion,  physical  signs,  G4 

emphysema,  56 

gangrene,  physical  signs,  62 

haemorrhage,  physical  sigus,62 

oedema,  61 

tuberculosis,  74 

valves,  82 
Pulsatile  empyema, diagnosed  from 

aneurism,  125 
Pulsation,     epigastric,     diagnosed 
from  aneurism.  125 

presystolic  jugular,  127 

systolic  jugular,  127 

venous,  127 
Pulse  curve,  246 

rate,  normal,  86 
"Purring  thrill,"  91 
Pus  in  fieces,  229 

in  sputum,  208 

in  urine,  195 

in  uriue,  microscopical  exami- 
nation, 220 

in  vomit,  228 
Pyelitis,  reaction  of  urine  in,  179 
Pyelonephritis,   reaction  of  urine 

in.  179 
Pyuria,  195 


Quain,  17,  236 


Rale,  crepitant,  42 

moist,  42 

mucous,  43 

redux,  43 

sonorous,  42 

subcrepitant,  43 
Rales,  classification  of,  40 
Ray  fungus,  in  sputum,  213 
Rectal  temperature.  ,56 
Red  blood  corpuscles,  199 
n  foeces,  2^9 

in  vomit,  228 
Reflecting  mirror,  240 
Region,  epigastric,  182 

epigastric,  contents  of,  134 

hypogastric.  134 

left  hypochondriac,  132 

left  hypochondriac,   contents 
of,  134 

!■  ft  iliac,  134 

left  iliac,  contents  of,  135 

left  lumbar,  133 


Region,  left  lumbar,  contents  of, 
134 

pubic,  134 

pubic,  contents  of,  134 

right  hypochondriac,  132 

right  hypochondriac,  contents 
of,  134 

right  iliac,  134 

right  iliac,  contents  of,  135 

right  lumbar,  133 

right  lumbar,  contents  of,  134 

umbilical,  133 

umbilical,  contents  of,  134 
I  egions  of  chest,  4 

axillary,  10 

clavicular,  4 

infra  axillary,  10 

infra-clavicular,  5 

infra-mammary,  6 

infra  scapular,  9 

inter-scapular,  9 

lower  sternal,  7 

mammary,  6 

scapular,  9 

supra-clavicular.  4 

supra-scapular,  9 

supra  sternal,  7 

upper  sternal,  7 
Relapsing  fever,  spirilla  in,  204 
Renal  epithelium  in  urine,  222 
Resonance,  amphoric,  26 

of  cough,  51 

cracked  pot,  26 

pulmonary,  exaggerated,  25 

tympanitic,  25 

vesiculotympanitic,  26 

whisper,  50 
Respiration,  absent  or  suppressed, 
35 

alteration  in  intensity,  34 

alteration  in  quality,  36 

alteration  in  rhythm,  35 

amphoric,  38 

bronchial,  33,  37 

cavernous,  37 

changes  from  normal,  34 

"cogged-wheel,"  35,  76 

diminished  or  feeble,  35 

exaggerated,  34 

interrupted.  35 

interval    between   inspiration 
and  expiration  prolonged,  36 

movements  of,  12 

normal     laryngeal     and     tra- 
cheal. 33 

rude,  36 
Rhinoscopic  image,  244 

mirror,  240 
Rhinoscopy,  242 
Rhubarb,  effect  on  color  of  urine, 

178 
Richardson,  39 


276 


INDEX. 


Right  hypochondriac  region,  132 

contents  of,  134 
Right  iliac  region,  134 

contents  of,  135 
Right  lumbar  region,  133 

contents  of,  134 
Roberts,  176 
Ronchial  fremitus,  1 6 
Rude  respiration,  36 
Rules  for  performing  percussion, 
21 


Saccharometer,  191 
Sarcinee  in  urine,  226 

ventriculi  in  vomit,  229 
Scapular,  infra-,  region,  9 

inter-,  region,  9 

supra-,  region,  9 
Seguin,  257 

Senna,  effect  on  color  of  urine,  178 
Sepulchral  cough,  51 
Sieveking.  264 
tfmpson,  143 
Sodium  urate,  215 
Sonorous  fremitus,  16 

rale,  42 
Sounds,  cardiac,  simulating  mur- 
murs, ill 
Spasmodic  asthma,  57 
Specula,  267 
Spermatozoa  in  urine,  223 

in  urine,  medico-leeal  cases, 
223 
Sphvgmoeraph,     description     of, 
244,  245 

in  aortic  regurgitation,  247 

in  aortic  stenosis,  248 

in  atheroma,  248 
Sp'  ygrmograms,  value  of,  246 
Spirillum  of  relapsing  fever,  204 
Spirometer,  Hutchison's,  IS 
Spleen,  diagnosis  of  diseases,  155, 
156 

enlargement  of,  154,  155 

enlargement  diagnosed    from 
disease  of  liver,  153 

method  of  determining  boun- 
daries, 153,  154 

normal  boundaries  of,  153 
Sputum,  actinomyces  in,  213 

amoeba  coli  in,  215 

cellular  elements,  207 

Curschmann's  spirals  in,  208 

elastic  tissue  in,  209 

epithelium  in,  207 

hydatids  in,  215 

liver  cells  in,  208 

pneumococcus  in,  213 

pus  cells  in,  208 

red  blood  cells  in,  208 

tubercle  bacillus  in,  210 


Sputum,  white  blood  cells  in,  208 
Sternal,  lower,  region,  7 

supra,  region,  7 

upper  region,  7 
Stethometer,  description  of,  236 

Quain's,  17 
Stethoscope,  29 

description  of,  235 
Stirling,  262 
Stomach,  cancer  of .  142 

diseases  of,  diagnosed  from  dis- 
ease of  liver,  153 

gaseous  or  tympanitic  disten- 
tion of,  142 

normal  boundaries  of,  141 
Subacute  pleurisy,  63 
Sub  clavian  murmurs,   diagnosed 

from  aneurism,  126 
Subcrepitant  rale,  43 
Succussion,  28 
Sugar  in  urine,  189 

in  urine,    Fehling's   test   for, 
190 

in  urine,  Trommers  test.  1^9 
Superior  sternal  region,  percussion 

of,  23 
Supra-clavicular  region,  4 
Supra-scapular    and   scapular    re- 
gions, percussion  of,  24 
Supra-sternal    region,   percussion 

of,  23 
Surface  thermometer,  257 
>ystole,  auricular,  84 

ventricular,  84 
Systolic  jugular  pulsation,  127 

venous  murmurs,  127 


Teenia  mediocanellata,  ova  of,  232 
solium,  ova  of,  232 

Tailed  cells  from  pelvis  of  kidney, 
222 

Temperature,  axillary,  257 

daily  variation  in  disease,  259- 

261 
range  of,  in  disease,  258 
range  of,  in  health,  258 
rectal.  257 

Thermometer,    axillary    tempera- 
ture, 257 
description  of,  256 
precautions  in  using,  257 
rectal  temperature,  257 
suiface,  257 

Thoma-Zeiss,  201 

Throat  mirror,  239 

Tinkling,  metallic,  51 

Topography  of  heart,  81 

I'orula  cerevisiae,  226 

Tracheophony,  47 

Trapp,  180 


INDEX. 


v;; 


Trichocephalus  dispar,  ova  of,  232 
Tricuspid  valve,  82 
Triple  phosphates  in  urine,  218 
Trommer's  test  for  sugar  in  urine, 

189 
Tubercle  bacillus  in  blood,  207 
bacillus  in  fasces.  231 
bacillus,  methods  of  staining, 

210,  ail,  212 
bacillus  in  sputum.  210 
bacillus  in  urine,  227 
bacillus  in  vomit,  229 
Tuberculosis,  pulmonary,  74 

pulmonary,  acute  miliary,  74 
pulmonary,  acute  pneumonic, 

75 
pulmonary,  chronic,  advanced 

stage,  77 
pulmonary,      chronic,      early 

stage,  75 
pulmonary,  inspection  in,  13 
Tumors,     abdominal,     diagnosed 
from   abdominal  aneurism, 
170 
melanotic,  color  of  urine  in,  178 
of  ovary,  1  65 
ovarian,  differential  diagnosis, 

166 
of  uterus,  164 
Turgescence  of  veins,  126 
Turpentine,   effect    on    odor     of 

urine,  178 
Tympanitic  resonance,  25 
Typhoid  bacillus,  207,  231 
Tyrosin  in  urine,  219 


Umbilical  region,  133 

region,  contents  of,  134 

zone,  boundaries  of,  132 
Upper  sternal  region,  7 
Urates,  effect  on  color  of  urine,  181 

in  urine,  215 

in  urine,  significance  of,  216 
Urea  in  urine,  181 
Ureometer,  description  of,  181 

method  of  using,  182 
Uric  acid  in  urine,  217 
Urine,  actinomyces  in,  227 

albumin,  qualitative  tests  for, 
187 

albumin,  quantitative  test,  188 

ammonio-magnesium    phos- 
phates in,  218 

amorphous  deposits,  215 

bile  in,  193 

blood  in,  194 

blood  in,  guaiacum  test,  19 1 

blood  in,  microscopical  exam- 
ination, 221 

blood  in,  significance  of ,  194 


Uriue,  blood  in,  spectroscopic  test 
for,  194 

calcium  oxalate  in,  217 

calcium  oxalate    in,     signifi- 
cance of,  218 

calcium  phosphate  in,  219 

calcium    phosphate  and   car- 
bonate in,  216 

casts  in,  223,  224,  225 

character  of  deposit,  180 

chemical  characters,  181 

chlorides  in,  185 

color  of,  178 

condition  of,  177 

cystin  in,  219 

diabetic,  color  of,  189 

diabetic,   specific  gravity   of, 
189 

echinococci  in,  227 

epithelium  in,  222 

fat  in.  216 

Fehling's  test   for    sugar   in, 
190 

fermentation    test  for  sugar, 
11)0 

filaria  in .  224 

gonococci  in,  226 

introductory  remarks,  175 

leucin  in,  219 

micrococcus  ureie  in,  226 

mucous  cylindroids  in,  220 

mucus  in,  220 

odor  of,  178 

penicilium  in,  226 

phosphates  in,  185 

phosphates,     clinical    signifi- 
cance of,  185 

physical  characters  of,  176 

plan  of  examination,  175 

pus  in,  195 

pus   in,  microscopical  exami- 
nation, 220 

pus  in,  origin  of,  221 

quantity    passed    in    twenty- 
four  hours,  176 

reaction,  179 

sarcina  in,  226 

significance  of  albumin  in,  189 

specific  gravity  of,  179 

specific    gravity,   amount    of 
solids  calculated  from,  180 

specific  gravity  in  disease,  180 

spermatozoa  in,  223 

sugar  in,  189 

sugar  in,  clinical  significance 
of,  193 

sugar,  fermentation  saccharo- 
meter,  191 

sugar,  quantitative  estimation 
of,  191 

sulphates  in,  186 

torula  in,  226 


27S 


INDEX. 


Urine,  triple  phosphates  in,  218 
Trommer's  test  for  sugar  in, 

189 
tubercle  bacilli  in,  237 
tyrosin  in,  219 
urates  in,  184,  215 
urates  in,  clinical  significance 

of,  184 
urea,  181 
urea,  clinical  significance  of, 

183 
urea,  quantitative   estimation 

of,  1M1 
uric  acid  in,  183,  217 
uric  acid,  cliuical  significance 

of,  184,  217 
uric  acid,  quantitative  estima- 
tion of,  184 
xanthin  in,  220 
Urinomeier,  180 
Urobilin,  178 
Uroerythrin,  178 
Uterine  bruit,  161 
Lterus,  160 

diagnosis  of  pregnancy,  160 
foetal  heart  sounds   162 
funic  souffle.  162 
rules  for  performing  ausculta- 
tion, 160 
tumors  of,  164 
twin  pregnancy,  1 63 


Vaginal  temperature,  257 
Veins,  turgescence  of,  126 
Venous  murmurs.  127 

murmurs,  diastolic,  128 
murmurs,  presystolic,  127 
murmurs,  systolic,  127 


Venous  pulsation,  127 

Ventricular  diastole,  85 
systole,  84 

Vesicular  murmur.  32 

Vesiculo  tympanitic  resonance,  26 

Vocal  fremitus,  absent.  15 
fremitus,  diminished,  15 
fremitus,  increased,  15 
fremitus,  normal,  15 
resonance,  exaggerated,  49 
resonance,    diminished  inten- 
sity, 48 
resonance,  increased  intensity, 

48 
resonance,  normal,  47 

Vomit,  --23 

epithelium  in,  229 

pus  in, 228 

red  blood  corpuscles  in,  228 

sarcinse  venlriculi  in,  229 

tubercle  bacilli  in,  229     ■ 

W 

Walsh,  57 
Waxy  casts,  224 

liver,  physical  signs,  147,  148 
Weber,  264 
Whisper  resonance,  50 
Woiller,  237 
"  Wool-sorter's"  disease,  206 


Xanthin  in  urine,  220 


Ziehl-Neelson  fuchsin,  210 
Zones  of  abdomen,  132 


COLUMBIA  UNIVERSITY 


0027717348 


